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O'Meara K, Stone G, Buch E, Brownstein A, Saggar R, Channick R, Sherman AE, Bender A. Atrial Arrhythmias in Patients With Pulmonary Hypertension. Chest 2024; 166:201-211. [PMID: 38453002 DOI: 10.1016/j.chest.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 03/09/2024] Open
Abstract
TOPIC IMPORTANCE Atrial arrhythmias (AA) are common in patients with pulmonary hypertension (PH) and contribute to morbidity and mortality. Given the growing PH population, understanding the pathophysiology, clinical impact, and management of AA in PH is important. REVIEW FINDINGS AA occurs in PH with a 5-year incidence of 10% to 25%. AA confers a higher morbidity and mortality, and restoration of normal sinus rhythm improves survival and functionality. AA is thought to develop because of structural alterations of the right atrium caused by changes to the right ventricle (RV) due to elevated pulmonary artery pressures. AA can subsequently worsen RV function. Current guidelines do not provide comprehensive recommendations for the management of AA in PH. Robust evidence to favor a specific treatment approach is lacking. Although the role of medical rate or rhythm control, and the use of cardioversion and ablation, can be inferred from other populations, evidence is lacking in the PH population. Much remains to be determined regarding the optimal management strategy. We present here our institutional approach and discuss areas for future research. SUMMARY This review highlights the epidemiology and pathophysiology of AA in patients with PH, describes the relationship between AA and RV dysfunction, and discusses current management practices. We outline our institutional approach and offer directions for future investigation.
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MESH Headings
- Humans
- Hypertension, Pulmonary/physiopathology
- Hypertension, Pulmonary/therapy
- Hypertension, Pulmonary/epidemiology
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/etiology
- Arrhythmias, Cardiac/physiopathology
- Arrhythmias, Cardiac/therapy
- Arrhythmias, Cardiac/epidemiology
- Arrhythmias, Cardiac/etiology
- Atrial Fibrillation/physiopathology
- Atrial Fibrillation/therapy
- Atrial Fibrillation/complications
- Atrial Fibrillation/epidemiology
- Ventricular Dysfunction, Right/physiopathology
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Affiliation(s)
- Kyle O'Meara
- Department of Pulmonary & Critical Care Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Gregory Stone
- UCLA Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Eric Buch
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Adam Brownstein
- Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Rajan Saggar
- Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Richard Channick
- Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Alexander E Sherman
- Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Aron Bender
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Xu W, Wang DY, Chen ZY, Gao Q, Zou YL, Sun DH, Zhang S, Zhao XB, Gong YT, Zhang Y, Zhang DX, Li Y. Noninvasive Stereotactic Radiotherapy for PADN in an Acute Canine Model of Pulmonary Arterial Hypertension. JACC Basic Transl Sci 2024; 9:244-256. [PMID: 38510719 PMCID: PMC10950402 DOI: 10.1016/j.jacbts.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 03/22/2024]
Abstract
This study assesses the feasibility, safety, and effectiveness of noninvasive stereotactic body radiotherapy (SBRT) as an approach for pulmonary artery denervation in canine models. SBRT with CyberKnife resulted in reduced mean pulmonary artery pressure, pulmonary capillary wedge pressure, and pulmonary vascular resistance, and insignificantly increased cardiac output. In comparison to the control group, serum norepinephrine levels at 1 month and 6 months were significantly lower in the CyberKnife group. Computed tomography, pulmonary angiography, and histology analysis revealed that SBRT was associated with minimal collateral damage.
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Affiliation(s)
- Wei Xu
- Department of Cardiology, the First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Ding-yu Wang
- Department of Cardiology, the First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Zi-yin Chen
- Department of Oncology, the First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Qiang Gao
- Department of Cardiology, the First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Yi-lun Zou
- Department of Cardiology, the First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Dang-hui Sun
- Department of Cardiology, the First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Song Zhang
- Department of Cardiology, the First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Xin-bo Zhao
- Department of Cardiology, the First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Yong-tai Gong
- Department of Cardiology, the First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Yun Zhang
- Department of Cardiology, the First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Da-xin Zhang
- Department of Oncology, the First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Yue Li
- Department of Cardiology, the First Affiliated Hospital, Harbin Medical University, Harbin, China
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, Harbin Medical University, Harbin, China
- NHC Key Laboratory of Cell Transplantation, Harbin Medical University, Harbin, Heilongjiang Province, China
- Institute of Metabolic Disease, Heilongjiang Academy of Medical Science, Harbin, China
- Heilongjiang Province Clinical Medical Research Center for Hypertension, the First Affiliated Hospital, Harbin Medical University, Harbin, China
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Mocumbi A, Humbert M, Saxena A, Jing ZC, Sliwa K, Thienemann F, Archer SL, Stewart S. Pulmonary hypertension. Nat Rev Dis Primers 2024; 10:1. [PMID: 38177157 DOI: 10.1038/s41572-023-00486-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 01/06/2024]
Abstract
Pulmonary hypertension encompasses a range of conditions directly or indirectly leading to elevated pressures within the pulmonary arteries. Five main groups of pulmonary hypertension are recognized, all defined by a mean pulmonary artery pressure of >20 mmHg: pulmonary arterial hypertension (rare), pulmonary hypertension associated with left-sided heart disease (very common), pulmonary hypertension associated with lung disease (common), pulmonary hypertension associated with pulmonary artery obstructions, usually related to thromboembolic disease (rare), and pulmonary hypertension with unclear and/or multifactorial mechanisms (rare). At least 1% of the world's population is affected, with a greater burden more likely in low-income and middle-income countries. Across all its forms, pulmonary hypertension is associated with adverse vascular remodelling with obstruction, stiffening and vasoconstriction of the pulmonary vasculature. Without proactive management this leads to hypertrophy and ultimately failure of the right ventricle, the main cause of death. In older individuals, dyspnoea is the most common symptom. Stepwise investigation precedes definitive diagnosis with right heart catheterization. Medical and surgical treatments are approved for pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. There are emerging treatments for other forms of pulmonary hypertension; but current therapy primarily targets the underlying cause. There are still major gaps in basic, clinical and translational knowledge; thus, further research, with a focus on vulnerable populations, is needed to better characterize, detect and effectively treat all forms of pulmonary hypertension.
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Affiliation(s)
- Ana Mocumbi
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Moçambique.
- Instituto Nacional de Saúde, EN 1, Marracuene, Moçambique.
| | - Marc Humbert
- Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre (Assistance Publique Hôpitaux de Paris), Université Paris-Saclay, INSERM UMR_S 999, Paris, France
- ERN-LUNG, Le Kremlin Bicêtre, Paris, France
| | - Anita Saxena
- Sharma University of Health Sciences, Haryana, New Delhi, India
| | - Zhi-Cheng Jing
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
| | - Karen Sliwa
- Cape Heart Institute, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
| | - Friedrich Thienemann
- Department of Medicine, Groote Schuur Hospital, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
- Department of Internal Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Stephen L Archer
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Simon Stewart
- Institute of Health Research, University of Notre Dame, Fremantle, Western Australia, Australia
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Yan J, Duan Y, Cheng M. Clinical Diagnostic Value of Serum GABA, NE, ET-1, and VEGF in Chronic Obstructive Pulmonary Disease with Pulmonary Hypertension. Int J Chron Obstruct Pulmon Dis 2023; 18:1803-1813. [PMID: 37621655 PMCID: PMC10445639 DOI: 10.2147/copd.s418478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023] Open
Abstract
Background Pulmonary hypertension (PH) is the one of the most common complications of chronic obstructive pulmonary disease (COPD). Whereas, the associated diagnostic factors are uncertain. The present study aims to investigate useful diagnostic factors in patients with COPD and PH (COPD-PH). Patients and Methods A total of 111 patients with COPD in Shanxi Bethune Hospital from December 2019 to December 2020 were divided into COPD (PASP≤50 mmHg) and COPD-PH groups (PASP>50 mmHg). Pulmonary function and chest CT results were collected. Routine blood, biochemical, and blood coagulation function indices were examined for all patients. Arterial blood gas analysis and serum cytokines were also measured. Differences in the distribution of the above indicators between the two groups were analyzed using binary logistic regression analysis to identify the risk factors of COPD-PH, and multiple linear regression analysis to determine the factors affecting PASP. The influencing factors and joint predictive factors of the above linear regression analysis were analyzed using the ROC curve. The area under the curve and the best cut-off value were calculated, and their predictive value and clinical significance in disease diagnosis were discussed. Results A total of 27 indexes with statistically significant differences between the two groups were identified (P < 0.05). Binary Logistic regression analysis showed that the factors influencing the diagnosis of pulmonary hypertension were serum GABA, NE, VEGF, BUN, and LYM% levels (P < 0.05). Multiple linear regression showed that the factors influencing PASP were serum NE, ET-1, GABA, and VEGF levels, and the goodness of fit of the model was 0.748 (P < 0.001). ROC curve showed that the AUC of the combined diagnosis of serum NE, ET-1, GABA, and VEGF levels was 0.966 (sensitivity, 87.5%; specificity, 93.65%). Conclusion Serum NE and ET-1 are risk factors for COPD-PH, whereas serum GABA and VEGF are protective factors against COPD-PH. The combined diagnostic value of serum NE, ET-1, GABA, and VEGF levels was the highest.
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Affiliation(s)
- Jing Yan
- Department of Respiratory and Critical Care Medicine, Lvliang People’s Hospital Affiliated to Shanxi Medical University, Lvliang City, Shanxi Province, 033000, People’s Republic of China
| | - Yajing Duan
- Department of Intensive Care Unit, Key Laboratory for Critical Care Medicine of the Ministry of Health, Emergency Medicine Research Institute, Tianjin First Center Hospital, Nankai University, Tianjin, 300192, People’s Republic of China
| | - Mengyu Cheng
- Department of Respiratory and Critical Care Medicine, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030032, People’s Republic of China
- Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
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Dayer N, Ltaief Z, Liaudet L, Lechartier B, Aubert JD, Yerly P. Pressure Overload and Right Ventricular Failure: From Pathophysiology to Treatment. J Clin Med 2023; 12:4722. [PMID: 37510837 PMCID: PMC10380537 DOI: 10.3390/jcm12144722] [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: 06/05/2023] [Revised: 07/01/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
Right ventricular failure (RVF) is often caused by increased afterload and disrupted coupling between the right ventricle (RV) and the pulmonary arteries (PAs). After a phase of adaptive hypertrophy, pressure-overloaded RVs evolve towards maladaptive hypertrophy and finally ventricular dilatation, with reduced stroke volume and systemic congestion. In this article, we review the concept of RV-PA coupling, which depicts the interaction between RV contractility and afterload, as well as the invasive and non-invasive techniques for its assessment. The current principles of RVF management based on pathophysiology and underlying etiology are subsequently discussed. Treatment strategies remain a challenge and range from fluid management and afterload reduction in moderate RVF to vasopressor therapy, inotropic support and, occasionally, mechanical circulatory support in severe RVF.
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Affiliation(s)
- Nicolas Dayer
- Department of Cardiology, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland;
| | - Zied Ltaief
- Department of Adult Intensive Care Medicine, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (Z.L.); (L.L.)
| | - Lucas Liaudet
- Department of Adult Intensive Care Medicine, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (Z.L.); (L.L.)
| | - Benoit Lechartier
- Department of Respiratory Medicine, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (B.L.); (J.-D.A.)
| | - John-David Aubert
- Department of Respiratory Medicine, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (B.L.); (J.-D.A.)
| | - Patrick Yerly
- Department of Cardiology, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland;
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Park DY, Heo W, Kang M, Ahn T, Kim D, Choi A, Birnbaumer L, Cho HJ, Kim JY. Role of TRPC3 in Right Ventricular Dilatation under Chronic Intermittent Hypoxia in 129/SvEv Mice. Int J Mol Sci 2023; 24:11284. [PMID: 37511045 PMCID: PMC10379021 DOI: 10.3390/ijms241411284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/30/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023] Open
Abstract
Patients with obstructive sleep apnea (OSA) exhibit a high prevalence of pulmonary hypertension and right ventricular (RV) hypertrophy. However, the exact molecule responsible for the pathogenesis remains unknown. Given the resistance to RV dilation observed in transient receptor potential canonical 3(Trpc3)-/- mice during a pulmonary hypertension model induced by phenylephrine (PE), we hypothesized that TRPC3 also plays a role in chronic intermittent hypoxia (CIH) conditions, which lead to RV dilation and dysfunction. To test this, we established an OSA mouse model using 8- to 12-week-old 129/SvEv wild-type and Trpc3-/- mice in a customized breeding chamber that simulated sleep and oxygen cycles. Functional parameters of the RV were evaluated through analysis of cardiac cine magnetic resonance images, while histopathological examinations were conducted on cardiomyocytes and pulmonary vessels. Following exposure to 4 weeks of CIH, Trpc3-/- mice exhibited significant RV dysfunction, characterized by decreased ejection fraction, increased end-diastole RV wall thickness, and elevated expression of pathological cardiac markers. In addition, reactive oxygen species (ROS) signaling and the endothelin system were markedly increased solely in the hearts of CIH-exposed Trpc3-/- mice. Notably, no significant differences in pulmonary vessel thickness or the endothelin system were observed in the lungs of wild-type (WT) and Trpc3-/- mice subjected to 4 weeks of CIH. In conclusion, our findings suggest that TRPC3 serves as a regulator of RV resistance in response to pressure from the pulmonary vasculature, as evidenced by the high susceptibility to RV dilation in Trpc3-/- mice without notable changes in pulmonary vasculature under CIH conditions.
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Affiliation(s)
- Do-Yang Park
- Department of Otolaryngology, Ajou University School of Medicine, Suwon 16499, Republic of Korea
| | - Woon Heo
- Department of Pharmacology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Miran Kang
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Taeyoung Ahn
- Department of Pharmacology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - DoHyeon Kim
- Department of Pharmacology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Ayeon Choi
- Department of Pharmacology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Lutz Birnbaumer
- Laboratory of Signal Transduction, National Institute of Environmental Health Sciences, Research Triangle Park, Durham, NC 27709, USA
- Institute of Biomedical Research (BIOMED), Catholic University of Argentina, Buenos Aires C1107AFF, Argentina
| | - Hyung-Ju Cho
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- The Airway Mucus Institute, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Joo Young Kim
- Department of Pharmacology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
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Tannu M, Krasuski RA. The Evolution of Pulmonary Artery Denervation for Treatment of Pulmonary Arterial Hypertension. Interv Cardiol Clin 2023; 12:381-391. [PMID: 37290841 DOI: 10.1016/j.iccl.2023.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a progressive, life-limiting disease. Despite significant medical progress over the last three decades, the prognosis of PAH remains poor. PAH is associated with sympathetic nervous system over-stimulation and baroreceptor-mediated vasoconstriction, leading to pathologic pulmonary artery (PA) and right ventricular remodeling. PA denervation is a minimally-invasive intervention that ablates local sympathetic nerve fibers and baroreceptors to modulate pathologic vasoconstriction. Preliminary animal and clinical studies have shown improvements in short-term pulmonary hemodynamics and PA remodeling. However, future studies are needed to elucidate appropriate patient selection, timing of intervention, and long-term efficacy before integration into standard of care.
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Affiliation(s)
- Manasi Tannu
- Division of Cardiology, Duke University Health System, DUMC 3012, Durham, NC 27710, USA
| | - Richard A Krasuski
- Division of Cardiology, Duke University Health System, DUMC 3012, Durham, NC 27710, USA.
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Orieux A, Samson C, Pieroni L, Drouin S, Dang Van S, Migeon T, Frere P, Brunet D, Buob D, Hadchouel J, Guihaire J, Mercier O, Galichon P. Pulmonary hypertension without heart failure causes cardiorenal syndrome in a porcine model. Sci Rep 2023; 13:9130. [PMID: 37277538 PMCID: PMC10241877 DOI: 10.1038/s41598-023-36124-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/30/2023] [Indexed: 06/07/2023] Open
Abstract
Cardiorenal syndromes type 1 and 2 are complex disorders in which cardiac dysfunction leads to kidney dysfunction. However, the mechanisms remain incompletely explained, during pulmonary hypertension in particular. The objective of this study is to develop an original preclinical model of cardiorenal syndrome secondary to a pulmonary hypertension in piglets. Twelve 2-month-old Large White piglets were randomized in two groups: (1) induction of pulmonary hypertension by ligation of the left pulmonary artery and iterative embolizations of the right lower pulmonary artery, or (2) Sham interventions. We evaluated the cardiac function using right heart catheterization, echocardiography and measurement of biochemistry markers). Kidney was characterized using laboratory blood and urine tests, histological evaluation, immunostainings for renal damage and repair, and a longitudinal weekly assessment of the glomerular filtration rate using creatinine-based estimation and intravenous injection of an exogenous tracer on one piglet. At the end of the protocol (6 weeks), the mean pulmonary artery pressure (32 ± 10 vs. 13 ± 2 mmHg; p = 0.001), pulmonary vascular resistance (9.3 ± 4.7 vs. 2.5 ± 0.4 WU; p = 0.004) and central venous pressure were significantly higher in the pulmonary hypertension group while the cardiac index was not different. Piglets with pulmonary hypertension had higher troponin I. We found significant tubular damage and an increase in albuminuria in the pulmonary hypertension group and negative correlation between pulmonary hypertension and renal function. We report here the first porcine model of cardiorenal syndrome secondary to pulmonary hypertension.
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Affiliation(s)
- Arthur Orieux
- INSERM UMR_S1155 Bâtiment Recherche, CoRaKiD, Hôpital Tenon, 4 Rue de La Chine, 75020, Paris, France
- Sorbonne Université, Paris, France
| | - Chloé Samson
- INSERM UMR_S1155 Bâtiment Recherche, CoRaKiD, Hôpital Tenon, 4 Rue de La Chine, 75020, Paris, France
- Sorbonne Université, Paris, France
| | - Laurence Pieroni
- INSERM UMR_S1155 Bâtiment Recherche, CoRaKiD, Hôpital Tenon, 4 Rue de La Chine, 75020, Paris, France
- Sorbonne Université, Paris, France
- AP-HP Hôpital Tenon - Service de Biochimie, Paris, France
| | - Sarah Drouin
- INSERM UMR_S1155 Bâtiment Recherche, CoRaKiD, Hôpital Tenon, 4 Rue de La Chine, 75020, Paris, France
- Sorbonne Université, Paris, France
- Service Médico Chirurgical de Transplantation Rénale, AP-HP Hôpital Pitié Salpêtrière, Paris, France
| | - Simon Dang Van
- INSERM UMR_S999, Hôpital Marie Lannelongue - Groupe Hospitalier Paris Saint Joseph, Le Plessis Robinson, France
- Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Chirurgie Thoracique et Transplantation Cardio-Thoracique, Hôpital Marie Lannelongue - Groupe Hospitalier Paris Saint Joseph, Le Plessis Robinson, France
| | - Tiffany Migeon
- INSERM UMR_S1155 Bâtiment Recherche, CoRaKiD, Hôpital Tenon, 4 Rue de La Chine, 75020, Paris, France
- Sorbonne Université, Paris, France
| | - Perrine Frere
- INSERM UMR_S1155 Bâtiment Recherche, CoRaKiD, Hôpital Tenon, 4 Rue de La Chine, 75020, Paris, France
- Sorbonne Université, Paris, France
| | - Dorothée Brunet
- INSERM UMR_S999, Hôpital Marie Lannelongue - Groupe Hospitalier Paris Saint Joseph, Le Plessis Robinson, France
- Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Chirurgie Thoracique et Transplantation Cardio-Thoracique, Hôpital Marie Lannelongue - Groupe Hospitalier Paris Saint Joseph, Le Plessis Robinson, France
| | - David Buob
- INSERM UMR_S1155 Bâtiment Recherche, CoRaKiD, Hôpital Tenon, 4 Rue de La Chine, 75020, Paris, France
- Sorbonne Université, Paris, France
- AP-HP Hôpital Tenon - Service d'Anatomie Pathologique, Paris, France
| | - Juliette Hadchouel
- INSERM UMR_S1155 Bâtiment Recherche, CoRaKiD, Hôpital Tenon, 4 Rue de La Chine, 75020, Paris, France
- Sorbonne Université, Paris, France
| | - Julien Guihaire
- INSERM UMR_S999, Hôpital Marie Lannelongue - Groupe Hospitalier Paris Saint Joseph, Le Plessis Robinson, France
- Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Chirurgie Thoracique et Transplantation Cardio-Thoracique, Hôpital Marie Lannelongue - Groupe Hospitalier Paris Saint Joseph, Le Plessis Robinson, France
| | - Olaf Mercier
- INSERM UMR_S999, Hôpital Marie Lannelongue - Groupe Hospitalier Paris Saint Joseph, Le Plessis Robinson, France
- Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Chirurgie Thoracique et Transplantation Cardio-Thoracique, Hôpital Marie Lannelongue - Groupe Hospitalier Paris Saint Joseph, Le Plessis Robinson, France
| | - Pierre Galichon
- INSERM UMR_S1155 Bâtiment Recherche, CoRaKiD, Hôpital Tenon, 4 Rue de La Chine, 75020, Paris, France.
- Sorbonne Université, Paris, France.
- Service Médico Chirurgical de Transplantation Rénale, AP-HP Hôpital Pitié Salpêtrière, Paris, France.
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9
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Association of hyponatremia with clinical outcomes in patients admitted with acute pulmonary embolism. J Thromb Thrombolysis 2023; 55:737-741. [PMID: 36745322 DOI: 10.1007/s11239-023-02783-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hyponatremia is associated with negative prognosis in several conditions like Congestive heart failure and acute MI (Myocardial Infarction), but its impact on the outcomes in patients with pulmonary embolism (PE) is not well studied. We aimed to study the association of hyponatremia in patients hospitalized with PE. METHODS A retrospective cohort study was designed using data obtained from the 2016 to 2019 combined National Inpatient Sample (NIS) database. Adult patients admitted with PE were identified and stratified based on the presence of hyponatremia. Primary outcomes assessed were, mortality, length of stay (LOS), and Total Hospitalization Charges (THC). Secondary outcomes included a diagnosis of Acute Kidney Injury (AKI), Acute Respiratory Failure (ARF), sepsis, Acute Cerebrovascular accident (CVA), arrhythmias and acute MI. Multivariate linear and logistic regressions were used to adjust for confounders. RESULTS There was a total of 750,655 adult hospitalizations for PE and among them 41,595 (5.5%) had a secondary diagnosis of hyponatremia. Hyponatremia was associated with an increased odds of mortality, 6.31% vs 2.91% (AOR:1.77, p = 0.000, 95% CI: 1.61-1.92), increased LOS, 6.79 days vs 4.20 days (adjusted difference of 2.20 days, p = 0.000, 95% CI: 2.04-2.37), as well as an increase in THC, 75,458.95 USD vs 46,708.27 USD (adjusted difference of 24,341.37 USD, p < 0.001, 95% CI: 21,484.58-27,198.16). Similarly, the presence of hyponatremia was associated with increased odds of several secondary outcomes measured. CONCLUSION Hyponatremia is associated with an increased odds of death and attendant increase in LOS and THC. The odds of several secondary adverse clinical outcomes were also increased.
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Madonna R, Ridolfi L, Morganti R, Biondi F, Fabiani S, Forniti A, Iapoce R, De Caterina R. Impact of Exercise-Induced Pulmonary Hypertension on Right Ventricular Function and on Worsening of Cardiovascular Risk in HIV Patients. J Clin Med 2022; 11:jcm11247349. [PMID: 36555965 PMCID: PMC9781486 DOI: 10.3390/jcm11247349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/03/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
Background and Aim: Exercise-induced pulmonary hypertension (ExPH) predicts clinical outcomes, such as all-cause mortality and cardiovascular (CV) hospitalizations, in patients with dyspnea on effort. We investigated its prognostic significance in human immunodeficiency virus (HIV)-affected patients. Methods: In 52 consecutive HIV patients with either low (n = 47) or intermediate probability (n = 5) of PH at rest, we evaluated—at time 0 and after 2 years—the prognostic determinants of CV risk, according to the 2015 European Society of Cardiology (ESC)/European Respiratory Society (ERS) Guidelines. Patients were classified with or without ExPH at stress echocardiography (ESE) and cardiopulmonary exercise test (CPET). We then related ExPH at time 0 with clinical worsening (CV risk score increase >20% after 2 years). Results: Right ventricle (RV) systolic function was significantly reduced in patients with ExPH compared to those without ExPH at CPET. This also occurred in patients with intermediate/high probability compared to those with low probability of ExPH at ESE. The former exhibited worse values of TAPSE and FAC (p < 0.001 and p = 0.01, respectively). A significantly higher proportion of patients with ExPH (CPET) or with intermediate/high probability of ExPH (ESE) had higher sPAP (p < 0.001), mPAP (p = 0.004) and higher TRV (p = 0.006), as well as higher right atrial area (p < 0.001) and indexed right atrial volume (p = 0.004). Total pulmonary vascular resistance (expressed by the ratio between TRV and the velocity-time integral at the level of the right ventricular outflow tract) was higher both in patients with ExPH and in those with intermediate/high probability of ExPH (p < 0.001). Patients with intermediate/high probability of ExPH at ESE showed a trend (p = 0.137) towards clinical worsening compared to those with low probability of ExPH. No patients with low probability of ExPH had a >20% increased CV risk score after 2 years. We found an association between higher NT-proBNP and the presence or intermediate/high probability of ExPH after 2 years (p = 0.048 at CPET, p = 0.033 at ESE). Conclusions: The assessment of ExPH may predict a trend of increasing CV risk score over time. If confirmed at a longer follow-up, ExPH could contribute to better risk stratification in HIV patients.
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Affiliation(s)
- Rosalinda Madonna
- Institute of Cardiology, Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy
- Correspondence:
| | - Lorenzo Ridolfi
- Institute of Cardiology, Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy
| | | | - Filippo Biondi
- Institute of Cardiology, Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy
| | - Silvia Fabiani
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy
| | - Arianna Forniti
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy
| | - Riccardo Iapoce
- Infectious Disease Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy
| | - Raffaele De Caterina
- Institute of Cardiology, Department of Pathology, Cardiology Division, Azienda Ospedaliera Universitaria Pisana, University of Pisa, 56124 Pisa, Italy
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11
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Davies MG, Miserlis D, Hart JP. Current status of pulmonary artery denervation. Front Cardiovasc Med 2022; 9:972256. [PMID: 36262207 PMCID: PMC9573987 DOI: 10.3389/fcvm.2022.972256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 09/02/2022] [Indexed: 11/22/2022] Open
Abstract
Pulmonary hypertension is a progressive disease with a poor long-term prognosis and high mortality. Pulmonary artery denervation (PADN) is emerging as a potential novel therapy for this condition. The basis of pursuing a sympathetic denervation strategy has its origins in a body of experimental translation work that has demonstrated that denervation can reduce sympathetic nerve activity in various animal models. This reduction in pulmonary sympathetic nerve activity is associated with a reduction in pathological pulmonary hemodynamics in response to mechanical, pharmacological, and toxicologically induced pulmonary hypertension. The most common method of PADN is catheter-directed thermal ablation. Since 2014, there have been 12 reports on the role of PADN in 490 humans with pulmonary hypertension (311:179; treated: control). Of these, six are case series, three are randomized trials, and three are case reports. Ten studies used percutaneous PADN techniques, and two combined PADN with mitral and/or left atrial surgery. PADN treatment has low mortality and morbidity and is associated with an improved 6-minute walking distance, a reduction in both mean pulmonary artery pressure and pulmonary vascular resistance, and an improvement in cardiac output. These improved outcomes were seen over a median follow-up of 12 months (range 2–46 months). A recent meta-analysis of human trials also supports the effectiveness of PADN in carefully selected patients. Based on the current literature, PADN can be effective in select patients with pulmonary hypertension. Additional randomized clinical trials against best medical therapy are required.
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Affiliation(s)
- Mark G. Davies
- Division of Vascular and Endovascular Surgery, The University of Texas Health at San Antonio, San Antonio, TX, United States,*Correspondence: Mark G. Davies
| | - Dimitrios Miserlis
- Division of Vascular and Endovascular Surgery, The University of Texas Health at San Antonio, San Antonio, TX, United States
| | - Joseph P. Hart
- Division of Vascular and Endovascular Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
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12
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Shah IK, Merfeld JM, Chun J, Tak T. Pathophysiology and Management of Pulmonary Embolism. Int J Angiol 2022; 31:143-149. [PMID: 36157092 PMCID: PMC9507564 DOI: 10.1055/s-0042-1756204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Pulmonary embolism (PE) is one of the most common etiologies of cardiovascular mortality. It could be linked to several risk factors including advanced age. The pathogenesis of PE is dictated by the Virchow's triad that includes venous stasis, endothelial injury, and a hypercoagulable state. The diagnosis of PE is difficult and is often missed due to the nonspecific symptomatology. Hypoxia is common in the setting of PE, and the degree of respiratory compromise is multifactorial and influenced by underlying cardiac function, clot location, and ability to compensate with respiratory mechanics. Right ventricular dysfunction/failure is the more profound cardiovascular impact of acute PE and occurs due to sudden increase in afterload. This is also the primary cause of death in PE. High clinical suspicion is required in those with risk factors and presenting signs or symptoms of venous thromboembolic disease, with validated clinical risk scores such as the Wells, Geneva, and pulmonary embolism rule out criteria in estimating the likelihood for PE. Advancement in capture time and wider availability of computed tomographic pulmonary angiography and D-dimer testing have further facilitated the rapid evaluation and diagnosis of suspected PE. Treatment is dependent on clinical presentation and initially involves providing adequate oxygenation and stabilizing hemodynamics. Anticoagulant therapy is indicated for the treatment of PE. Treatment is guided by presence or absence of shock and ranges from therapeutic anticoagulation to pharmacologic versus mechanical thrombectomy. The prognosis of patients can vary considerably depending on the cardiac and pulmonary status of patient and the size of the embolus.
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Affiliation(s)
- Ishan K. Shah
- Department of Family Medicine, Mayo Clinic Health System, La Crosse, Wisconsin
| | - John M. Merfeld
- Department of Family Medicine, Mayo Clinic Health System, La Crosse, Wisconsin
| | - Jimy Chun
- Department of Nephrology, Mayo Clinic, La Crosse, Wisconsin
| | - Tahir Tak
- Department of Cardiovascular Diseases, Mayo Clinic Health System, La Crosse, Wisconsin
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester. Minnesota
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13
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Hyder SN, Chatterjee S, Aggarwal V. Percutaneous Treatments for Pulmonary Hypertension: Reviewing the Growing Procedural Role for Interventional Cardiology. Interv Cardiol Clin 2022; 11:293-305. [PMID: 35710284 DOI: 10.1016/j.iccl.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Pulmonary arterial hypertension is a common and highly morbid medical problem resulting in elevated pulmonary arterial pressures and pulmonary vascular resistance. Medical therapies are costly, and not always well-tolerated. Surgical therapies such as pulmonary endarterectomy and lung transplantation are limited to a small subset of patients due to various patient, disease, or institutional factors. Over the past decade, there has been growing investigation into endovascular interventional therapies for patients with pulmonary hypertension such as balloon pulmonary angioplasty and pulmonary denervation. In this review, we describe the current status, future directions, and our recommendations on technical considerations with these therapies.
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Affiliation(s)
- S Nabeel Hyder
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan Medical School, 1500 East, Medical Center Drive, SPC 5860, Ann Arbor, MI 48109, USA
| | - Saurav Chatterjee
- Division of Cardiovascular Medicine, North Shore-Long Island Jewish Medical Centers, Northwell Health, Zucker School of Medicine, 270-05 76(th) Avenue, New Hyde Park, NY 11040, USA
| | - Vikas Aggarwal
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan Medical School, 1500 East, Medical Center Drive, SPC 5860, Ann Arbor, MI 48109, USA.
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14
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Varma PK, Jose RL, Krishna N, Srimurugan B, Valooran GJ, Jayant A. Perioperative right ventricular function and dysfunction in adult cardiac surgery-focused review (part 1-anatomy, pathophysiology, and diagnosis). Indian J Thorac Cardiovasc Surg 2022; 38:45-57. [PMID: 34898875 PMCID: PMC8630124 DOI: 10.1007/s12055-021-01240-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 01/03/2023] Open
Abstract
Right ventricle (RV) dysfunction and failure are now increasingly recognized as an important cause of perioperative morbidity and mortality after cardiac surgery. Although RV dysfunction is common, RV failure is very rare (0.1%) after routine cardiac surgery. However, it occurs in 3% of patients after heart transplantation and in up to 30% of patients after left ventricular assist device implantation. Significant RV failure after cardiac surgery has high mortality. Knowledge of RV anatomy and physiology are important for understanding RV dysfunction and failure. Echocardiography and haemodynamic monitoring are the mainstays in the diagnosis of RV dysfunction and failure. While detailed echocardiography assessment of right heart function has been extensively studied and validated in the elective setting, gross estimation of RV chamber size, function, and some easily obtained quantitative parameters on transesophageal echocardiography are useful in the perioperative setting. However, detailed knowledge of echocardiography parameters is still useful in understanding the differences in contractile pattern, ventriculo-arterial coupling, and interventricular dependence that ensue after open cardiac surgery. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s12055-021-01240-y.
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Affiliation(s)
- Praveen Kerala Varma
- Divisions of Cardiovascular & Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Reshmi Liza Jose
- Divisions of Cardiac Anesthesiology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Neethu Krishna
- Divisions of Cardiovascular & Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Balaji Srimurugan
- Divisions of Cardiovascular & Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | | | - Aveek Jayant
- Divisions of Cardiac Anesthesiology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
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15
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Itelman E, Segel MJ, Kuperstein R, Feinberg M, Segev A, Segal G, Maor E, Grossman E. Pulmonary Hypertension Is Associated With Systemic Arterial Hypertension Among Patients With Normal Left Ventricular Diastolic Function. J Am Heart Assoc 2021; 10:e023603. [PMID: 34873923 PMCID: PMC9075261 DOI: 10.1161/jaha.121.023603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background The association of pulmonary and systemic arterial hypertension is believed to be mediated through hypertensive left heart disease. The purpose of the current study was to investigate whether pulmonary hypertension (PHT) is associated with systemic arterial hypertension among patients with apparently normal left ventricular diastolic function. Methods and Results Consecutive patients who had echocardiographic evaluation between 2007 and 2019 were enrolled. Patients with disease states that are known to be associated with PHT, including diastolic dysfunction, were excluded from the analysis. Estimated right ventricular systolic pressure was extracted for all patients from the echocardiographic reports. PHT was defined as estimated right ventricular systolic pressure >40 mm Hg. Multivariate logistic regression models were applied. Final study population included 25 916 patients with a median age of 59 (interquartile range, 44–69) years, of whom 12 501 (48%) were men and 13 265 (51%) had systemic arterial hypertension. Compared with normotensive patients, hypertensive patients were 3.2 times more likely to have PHT (95% CI, 2.91–3.53; P<0.001). A multivariate model adjusted for clinical and echocardiographic parameters that are known to be associated with PHT demonstrated that hypertensive patients are almost 3 times more likely to have PHT (95% CI, 2.45–3.15; P<0.001). The association was significant in multiple subgroups but was more significant among women compared with men (odds ratio, 3.1 versus 2.4; P for interaction <0.001). Conclusions PHT is associated with systemic arterial hypertension irrespective of left heart disease. The association is more pronounced among women.
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Affiliation(s)
- Edward Itelman
- Internal Medicine Ward "T" Chaim Sheba Medical Center Ramat Gan Israel.,Sackler Faculty of Medicine Tel-Aviv University Tel Aviv Israel
| | - Michael J Segel
- Sackler Faculty of Medicine Tel-Aviv University Tel Aviv Israel.,Department of Pulmonology Chaim Sheba Medical Center Ramat Gan Israel
| | - Rafael Kuperstein
- Sackler Faculty of Medicine Tel-Aviv University Tel Aviv Israel.,Leviev Heart Center Chaim Sheba Medical Center Ramat Gan Israel
| | - Micha Feinberg
- Sackler Faculty of Medicine Tel-Aviv University Tel Aviv Israel.,Leviev Heart Center Chaim Sheba Medical Center Ramat Gan Israel
| | - Amit Segev
- Sackler Faculty of Medicine Tel-Aviv University Tel Aviv Israel.,Leviev Heart Center Chaim Sheba Medical Center Ramat Gan Israel
| | - Gad Segal
- Internal Medicine Ward "T" Chaim Sheba Medical Center Ramat Gan Israel.,Sackler Faculty of Medicine Tel-Aviv University Tel Aviv Israel
| | - Elad Maor
- Sackler Faculty of Medicine Tel-Aviv University Tel Aviv Israel.,Leviev Heart Center Chaim Sheba Medical Center Ramat Gan Israel
| | - Ehud Grossman
- Sackler Faculty of Medicine Tel-Aviv University Tel Aviv Israel.,Internal Medicine Wing Chaim Sheba Medical Center Ramat Gan Israel
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16
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Jin Q, Li X, Zhang Y, Zhao Z, Zhao Q, Yan L, Duan A, Luo Q, Liu Z. Heart Rate Recovery at 1 Min after Exercise Is a Marker of Disease Severity and Prognosis in Chronic Thromboembolic Pulmonary Hypertension. Respiration 2021; 101:455-464. [PMID: 34903700 DOI: 10.1159/000520314] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/08/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Attenuated heart rate recovery at 1 min (HRR1) was demonstrated to correlate with poor prognosis in patients with pulmonary arterial hypertension, whereas its role in patients with chronic thromboembolic pulmonary hypertension (CTEPH) remains unclear. OBJECTIVES The aim of this study was to investigate the correlations between HRR1 and functional status, echocardiography, hemodynamics, and prognosis of CTEPH. METHODS We retrospectively enrolled patients with CTEPH who underwent right heart catheterization and cardiopulmonary exercise test between June 2014 to October 2020 in Fuwai hospital. The primary outcome was clinical worsening. Linear regression was performed to assess the association between HRR1 and established markers of CTEPH severity. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff of HRR1. Cox regression models were used to assess the association between HRR1 and clinical worsening. RESULTS A total of 211 patients with CTEPH were included in the study. After adjusting for confounders, HRR1 positively correlated with 6-min walk distance, mixed venous oxygen saturation, and peak oxygen consumption, and negatively correlated with NT-proBNP, pulmonary vascular resistance, and ventilatory equivalent of carbon dioxide. Compared with patients with HRR1 ≥16 beats, patients with HRR1 <16 beats had approximately a 3-fold risk of experiencing clinical worsening and the risk escalated with time. CONCLUSION HRR1 could reflect disease severity and was independently associated with prognosis in patients with CTEPH.
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Affiliation(s)
- Qi Jin
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin Li
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Zhang
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhihui Zhao
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qing Zhao
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Yan
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Anqi Duan
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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17
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Zolty R. Novel Experimental Therapies for Treatment of Pulmonary Arterial Hypertension. J Exp Pharmacol 2021; 13:817-857. [PMID: 34429666 PMCID: PMC8380049 DOI: 10.2147/jep.s236743] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 07/07/2021] [Indexed: 12/18/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive and devastating disease characterized by pulmonary artery vasoconstriction and vascular remodeling leading to vascular rarefaction with elevation of pulmonary arterial pressures and pulmonary vascular resistance. Often PAH will cause death from right heart failure. Current PAH-targeted therapies improve functional capacity, pulmonary hemodynamics and reduce hospitalization. Nevertheless, today PAH still remains incurable and is often refractory to medical therapy, underscoring the need for further research. Over the last three decades, PAH has evolved from a disease of unknown pathogenesis devoid of effective therapy to a condition whose cellular, genetic and molecular underpinnings are unfolding. This article provides an update on current knowledge and summarizes the progression in recent advances in pharmacological therapy in PAH.
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Affiliation(s)
- Ronald Zolty
- Pulmonary Hypertension Program, University of Nebraska Medical Center, Lied Transplant Center, Omaha, NE, USA
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18
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Peters EL, Bogaard HJ, Vonk Noordegraaf A, de Man FS. Neurohormonal modulation in pulmonary arterial hypertension. Eur Respir J 2021; 58:13993003.04633-2020. [PMID: 33766951 PMCID: PMC8551560 DOI: 10.1183/13993003.04633-2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 03/13/2021] [Indexed: 12/15/2022]
Abstract
Pulmonary hypertension is a fatal condition of elevated pulmonary pressures, complicated by right heart failure. Pulmonary hypertension appears in various forms; one of those is pulmonary arterial hypertension (PAH) and is particularly characterised by progressive remodelling and obstruction of the smaller pulmonary vessels. Neurohormonal imbalance in PAH patients is associated with worse prognosis and survival. In this back-to-basics article on neurohormonal modulation in PAH, we provide an overview of the pharmacological and nonpharmacological strategies that have been tested pre-clinically and clinically. The benefit of neurohormonal modulation strategies in PAH patients has been limited by lack of insight into how the neurohormonal system is changed throughout the disease and difficulties in translation from animal models to human trials. We propose that longitudinal and individual assessments of neurohormonal status are required to improve the timing and specificity of neurohormonal modulation strategies. Ongoing developments in imaging techniques such as positron emission tomography may become helpful to determine neurohormonal status in PAH patients in different disease stages and optimise individual treatment responses.
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Affiliation(s)
- Eva L Peters
- Dept of Pulmonology, Amsterdam UMC, Amsterdam, The Netherlands.,Dept of Physiology, Amsterdam UMC, Amsterdam, The Netherlands
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19
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Sun XQ, Peters EL, Schalij I, Axelsen JB, Andersen S, Kurakula K, Gomez-Puerto MC, Szulcek R, Pan X, da Silva Goncalves Bos D, Schiepers REJ, Andersen A, Goumans MJ, Vonk Noordegraaf A, van der Laarse WJ, de Man FS, Bogaard HJ. Increased MAO-A Activity Promotes Progression of Pulmonary Arterial Hypertension. Am J Respir Cell Mol Biol 2021; 64:331-343. [PMID: 33264068 DOI: 10.1165/rcmb.2020-0105oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Monoamine oxidases (MAOs), a class of enzymes bound to the outer mitochondrial membrane, are important sources of reactive oxygen species. Increased MAO-A activity in endothelial cells and cardiomyocytes contributes to vascular dysfunction and progression of left heart failure. We hypothesized that inhibition of MAO-A can be used to treat pulmonary arterial hypertension (PAH) and right ventricular (RV) failure. MAO-A levels in lung and RV samples from patients with PAH were compared with levels in samples from donors without PAH. Experimental PAH was induced in male Sprague-Dawley rats by using Sugen 5416 and hypoxia (SuHx), and RV failure was induced in male Wistar rats by using pulmonary trunk banding (PTB). Animals were randomized to receive either saline or the MAO-A inhibitor clorgyline at 10 mg/kg. Echocardiography and RV catheterization were performed, and heart and lung tissues were collected for further analysis. We found increased MAO-A expression in the pulmonary vasculature of patients with PAH and in experimental experimental PAH induced by SuHx. Cardiac MAO-A expression and activity was increased in SuHx- and PTB-induced RV failure. Clorgyline treatment reduced RV afterload and pulmonary vascular remodeling in SuHx rats through reduced pulmonary vascular proliferation and oxidative stress. Moreover, clorgyline improved RV stiffness and relaxation and reversed RV hypertrophy in SuHx rats. In PTB rats, clorgyline had no direct clorgyline had no direct effect on the right ventricle effect. Our study reveals the role of MAO-A in the progression of PAH. Collectively, these findings indicated that MAO-A may be involved in pulmonary vascular remodeling and consecutive RV failure.
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Affiliation(s)
- Xiao-Qing Sun
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences Research Institute, and
| | - Eva L Peters
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences Research Institute, and.,Amsterdam University Medical Center, Department of Physiology, Free University, Amsterdam, the Netherlands
| | - Ingrid Schalij
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences Research Institute, and
| | - Julie Birkmose Axelsen
- Institute of Clinical Medicine, Department of Cardiology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark; and
| | - Stine Andersen
- Institute of Clinical Medicine, Department of Cardiology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark; and
| | - Kondababu Kurakula
- Laboratory for Cardiovascular Cell Biology, Department of Cell and Chemical Biology
| | - Maria Catalina Gomez-Puerto
- Department of Cell and Chemical Biology, Leiden University Medical Center, and.,Oncode Institute, Leiden University-Oncode Institute, Leiden, the Netherlands
| | - Robert Szulcek
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences Research Institute, and
| | - Xiaoke Pan
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences Research Institute, and
| | | | - Roy E J Schiepers
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences Research Institute, and
| | - Asger Andersen
- Institute of Clinical Medicine, Department of Cardiology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark; and
| | - Marie-José Goumans
- Laboratory for Cardiovascular Cell Biology, Department of Cell and Chemical Biology
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences Research Institute, and
| | - Willem J van der Laarse
- Amsterdam University Medical Center, Department of Physiology, Free University, Amsterdam, the Netherlands
| | - Frances S de Man
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences Research Institute, and
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences Research Institute, and
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20
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Dignam JP, Scott TE, Kemp-Harper BK, Hobbs AJ. Animal models of pulmonary hypertension: Getting to the heart of the problem. Br J Pharmacol 2021; 179:811-837. [PMID: 33724447 DOI: 10.1111/bph.15444] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/04/2021] [Accepted: 03/06/2021] [Indexed: 12/12/2022] Open
Abstract
Despite recent therapeutic advances, pulmonary hypertension (PH) remains a fatal disease due to the development of right ventricular (RV) failure. At present, no treatments targeted at the right ventricle are available, and RV function is not widely considered in the preclinical assessment of new therapeutics. Several small animal models are used in the study of PH, including the classic models of exposure to either hypoxia or monocrotaline, newer combinational and genetic models, and pulmonary artery banding, a surgical model of pure RV pressure overload. These models reproduce selected features of the structural remodelling and functional decline seen in patients and have provided valuable insight into the pathophysiology of RV failure. However, significant reversal of remodelling and improvement in RV function remains a therapeutic obstacle. Emerging animal models will provide a deeper understanding of the mechanisms governing the transition from adaptive remodelling to a failing right ventricle, aiding the hunt for druggable molecular targets.
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Affiliation(s)
- Joshua P Dignam
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Tara E Scott
- Department of Pharmacology, Cardiovascular Disease Program, Biomedicine Discovery Institute, Monash University Clayton Campus, Clayton, Victoria, Australia.,Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University Parkville Campus, Parkville, Victoria, Australia
| | - Barbara K Kemp-Harper
- Department of Pharmacology, Cardiovascular Disease Program, Biomedicine Discovery Institute, Monash University Clayton Campus, Clayton, Victoria, Australia
| | - Adrian J Hobbs
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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21
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Harbrücker M, Natale M, Kim SH, Müller J, Ansari U, Huseynov A, Zworowsky MV, Borggrefe M, Hoffmann U, Lang S, Fatar M, Roth T, Kittel M, Bertsch T, Akin I, Behnes M. Copeptin reliably reflects longitudinal right ventricular function. Ann Clin Biochem 2021; 58:270-279. [PMID: 33430599 DOI: 10.1177/0004563221989364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Data is limited evaluating novel biomarkers in right ventricular dysfunction. Normal right heart function improves the prognosis of patients with heart failure. Therefore, this study investigates the association between the novel biomarker copeptin and right heart function compared to NT-proBNP. METHODS Patients undergoing routine echocardiography were enrolled prospectively. Right ventricular function was assessed by tricuspid annular plane systolic excursion (TAPSE) and further right ventricular and atrial parameters. Exclusion criteria were age under 18 years, left ventricular ejection fraction < 50% and moderate to severe valvular heart disease. Blood samples were taken for biomarker measurements within 72 h of echocardiography. RESULTS Ninety-one patients were included. Median values of copeptin increased significantly according to decreasing values of TAPSE (P = 0.001; right heart function grade I: tricuspid annular plane systolic excursion; TAPSE > 24 mm: 5.20 pmol/L; grade II: TAPSE 18-24 mm: 8.10 pmol/L; grade III: TAPSE < 18 mm: 26.50 pmol/L). Copeptin concentrations were able to discriminate patients with decreased right heart function defined as TAPSE < 18 mm (area under the curves [AUC]: copeptin: 0.793; P = 0.001; NT-proBNP: 0.805; P = 0.0001). Within a multivariable linear regression model, copeptin was independently associated with TAPSE (copeptin: T: -4.43; P = 0.0001; NT-proBNP: T: -1.21; P = 0.23). Finally, copeptin concentrations were significantly associated with severely reduced right heart function (TAPSE < 18 mm) within a multivariate logistic regression model (copeptin: odds ratio: 0.94; 95% confidence interval: 0.911-0.975; P = 0.001). CONCLUSIONS This study demonstrates that the novel biomarker copeptin reflects longitudinal right heart function assessed by standardized transthoracic echocardiography compared with NT-proBNP.
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Affiliation(s)
- Melissa Harbrücker
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michèle Natale
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Seung-Hyun Kim
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Julian Müller
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Uzair Ansari
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Aydin Huseynov
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Max von Zworowsky
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ursula Hoffmann
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Siegfried Lang
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Marc Fatar
- Department of Neurology (M.F.), University Medical Centre Mannheim, Mannheim, Germany
| | - Thomas Roth
- Central Laboratory (T.R.), University Hospital Erlangen, Erlangen, Germany
| | - Maximilian Kittel
- Faculty of Medicine Mannheim, Institute of Clinical Chemistry and Laboratory Medicine (M.K.), University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine (T.B.), Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
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Pływaczewska M, Pruszczyk P, Kostrubiec M. Does kidney function matter in pulmonary thromboembolism management? Cardiol J 2021; 29:858-865. [PMID: 33470418 PMCID: PMC9550328 DOI: 10.5603/cj.a2021.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/30/2020] [Accepted: 12/22/2020] [Indexed: 11/25/2022] Open
Abstract
Cardiovascular circulation and kidney function are closely interrelated. The impairment of renal function is a well-known hazard of increased mortality and morbidity of patients with heart failure or coronary artery disease. Acute pulmonary embolism (APE) impacts pulmonary and systemic circulation, and can severely impair functions of other organs, including kidneys, as a result of hypoxemia and increased venous pressure. Previous studies indicate that renal dysfunction predicts short- and long-term outcomes and can improve the risk assessment in APE. However, renal function should also be cautiously considered during the diagnostic workup because the contrast-induced nephropathy after computed tomography pulmonary angiography is noticed more frequently in APE. Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but imminent complication of APE. This condition promotes renal impairment by increasing venous pressure and decreasing glomerular filtration. The renal function improvement and serum creatinine concentration reduction were noted in CTEPH subgroup with glomerular filtration rate ≤ 60 mL/min/1.73 m2 after successful treatment. In this review, we present the essential research results on the kidney function in thromboembolism disease.
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Affiliation(s)
| | - Piotr Pruszczyk
- Department of Inter nal Medicine and Car diology, Medical University of Warsaw, Poland
| | - Maciej Kostrubiec
- Department of Inter nal Medicine and Car diology, Medical University of Warsaw, Poland
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Neurohormonal Modulation as a Therapeutic Target in Pulmonary Hypertension. Cells 2020; 9:cells9112521. [PMID: 33266371 PMCID: PMC7700466 DOI: 10.3390/cells9112521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 12/14/2022] Open
Abstract
The autonomic nervous system (ANS) and renin-angiotensin-aldosterone system (RAAS) are involved in many cardiovascular disorders, including pulmonary hypertension (PH). The current review focuses on the role of the ANS and RAAS activation in PH and updated evidence of potential therapies targeting both systems in this condition, particularly in Groups 1 and 2. State of the art knowledge in preclinical and clinical use of pharmacologic drugs (beta-blockers, beta-three adrenoceptor agonists, or renin-angiotensin-aldosterone signaling drugs) and invasive procedures, such as pulmonary artery denervation, is provided.
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24
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Klinke A, Schubert T, Müller M, Legchenko E, Zelt JGE, Shimauchi T, Napp LC, Rothman AMK, Bonnet S, Stewart DJ, Hansmann G, Rudolph V. Emerging therapies for right ventricular dysfunction and failure. Cardiovasc Diagn Ther 2020; 10:1735-1767. [PMID: 33224787 PMCID: PMC7666928 DOI: 10.21037/cdt-20-592] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/27/2020] [Indexed: 12/17/2022]
Abstract
Therapeutic options for right ventricular (RV) dysfunction and failure are strongly limited. Right heart failure (RHF) has been mostly addressed in the context of pulmonary arterial hypertension (PAH), where it is not possible to discern pulmonary vascular- and RV-directed effects of therapeutic approaches. In part, opposing pathomechanisms in RV and pulmonary vasculature, i.e., regarding apoptosis, angiogenesis and proliferation, complicate addressing RHF in PAH. Therapy effective for left heart failure is not applicable to RHF, e.g., inhibition of adrenoceptor signaling and of the renin-angiotensin system had no or only limited success. A number of experimental studies employing animal models for PAH or RV dysfunction or failure have identified beneficial effects of novel pharmacological agents, with most promising results obtained with modulators of metabolism and reactive oxygen species or inflammation, respectively. In addition, established PAH agents, in particular phosphodiesterase-5 inhibitors and soluble guanylate cyclase stimulators, may directly address RV integrity. Promising results are furthermore derived with microRNA (miRNA) and long non-coding RNA (lncRNA) blocking or mimetic strategies, which can target microvascular rarefaction, inflammation, metabolism or fibrotic and hypertrophic remodeling in the dysfunctional RV. Likewise, pre-clinical data demonstrate that cell-based therapies using stem or progenitor cells have beneficial effects on the RV, mainly by improving the microvascular system, however clinical success will largely depend on delivery routes. A particular option for PAH is targeted denervation of the pulmonary vasculature, given the sympathetic overdrive in PAH patients. Finally, acute and durable mechanical circulatory support are available for the right heart, which however has been tested mostly in RHF with concomitant left heart disease. Here, we aim to review current pharmacological, RNA- and cell-based therapeutic options and their potential to directly target the RV and to review available data for pulmonary artery denervation and mechanical circulatory support.
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Affiliation(s)
- Anna Klinke
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Torben Schubert
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Marion Müller
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Ekaterina Legchenko
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Jason G. E. Zelt
- Division of Cardiology, University of Ottawa Heart Institute and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Tsukasa Shimauchi
- Pulmonary Hypertension Research Group, Centre de recherche de IUCPQ/Laval University, Quebec, Canada
| | - L. Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | - Sébastien Bonnet
- Pulmonary Hypertension Research Group, Centre de recherche de IUCPQ/Laval University, Quebec, Canada
| | - Duncan J. Stewart
- Division of Cardiology, University of Ottawa Heart Institute and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Volker Rudolph
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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25
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Pulmonary artery denervation for pulmonary arterial hypertension. Trends Cardiovasc Med 2020; 31:252-260. [PMID: 32413394 DOI: 10.1016/j.tcm.2020.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 01/18/2023]
Abstract
Pulmonary arterial hypertension remains a progressive, life-limiting disease despite optimal medical therapy. Pulmonary artery denervation has arisen as a novel intervention in the treatment of pulmonary arterial hypertension, and other forms of pulmonary hypertension, with the aim of reducing the sympathetic activity of the pulmonary circulation. Pre-clinical studies and initial clinical trials have demonstrated that the technique can be performed safely with some positive effects on clinical, haemodynamic and echocardiographic markers of disease. The scope of the technique in current practice remains limited given the absence of well-designed, large-scale, international randomised controlled clinical trials. This review provides an overview of this exciting new treatment modality, including pathophysiology, technical innovations and recent trial results.
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Abstract
The plasma proteome is rich in information. It comprises proteins that are secreted or lost from cells as they respond to their local environment. Changes in the constitution of the plasma proteome offer a relatively non-invasive report on the health of tissues. This is particularly true of the lung in pulmonary hypertension, given the large surface area of the pulmonary vasculature in direct communication with blood. So far, this is relatively untapped; we have relied on proteins released from the heart, specifically brain natriuretic peptide and troponin, to inform clinical management. New technology allows the measurement of a larger number of proteins that cover a broad range of molecular pathways in a single small aliquot. The emerging data will yield more than just new biomarkers of pulmonary hypertension for clinical use. Integrated with genomics and with the help of new bioinformatic tools, the plasma proteome can provide insight into the causative drivers of pulmonary vascular disease and guide drug development.
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Affiliation(s)
- Martin Wilkins
- Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, United Kingdom
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27
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Rijnierse MT, Groeneveldt JA, van Campen JSJA, de Boer K, van der Bruggen CEE, Harms HJ, Raijmakers PG, Lammertsma AA, Knaapen P, Bogaard HJ, Westerhof BE, Vonk Noordegraaf A, Allaart CP, de Man FS. Bisoprolol therapy does not reduce right ventricular sympathetic activity in pulmonary arterial hypertension patients. Pulm Circ 2020; 10:2045894019873548. [PMID: 32363028 PMCID: PMC7187746 DOI: 10.1177/2045894019873548] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 07/29/2019] [Indexed: 11/27/2022] Open
Abstract
Right ventricular (RV) function and autonomic dysfunction are important
determinants of morbidity and mortality in patients with pulmonary arterial
hypertension (PAH). Although successful in animal studies, effects of
beta-blocker therapy on RV function in clinical trials were disappointing. To
understand this discrepancy, we studied whether beta-blocker therapy changes RV
sympathetic activity. Idiopathic PAH (IPAH) patients received beta-blocker
therapy (uptitrated to a maximal tolerated dose) and underwent cardiac magnetic
resonance imaging, right heart catheterization, and a
[11C]-hydroxyephedrine positron emission tomography
([11C]HED PET) scan at baseline to determine, respectively, RV
ejection fraction (RVEF), RV pressures, and sympathetic activity.
[11C]HED, a norepinephrine analogue, allows determination of
sympathetic innervation of the RV. [11C]HED retention index reflects
norepinephrine transporter activity. As a consequence of excessive catecholamine
levels in the synaptic cleft, this transporter may be downregulated. Therefore,
low [11C]HED retention index indicates high sympathetic activity. 13
IPAH patients underwent [11C]HED PET scans at baseline and after
bisoprolol treatment. Although heart rate was reduced, systemic modulation of
autonomic activity by bisoprolol did not affect local RV sympathetic nerve
activity, RV function, or RV wall tension. In PAH patients, RV
[11C]HED retention index was lower compared to LV tracer uptake
(p<0.01) and was related to systolic wall tension (R2 = 0.4731,
p<0.01) and RV function (R2 = 0.44, p = 0.01). In RV failure, the
tolerated dosage of bisoprolol did not result in an improvement of RV function
nor in a reduction in RV sympathetic activity.
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Affiliation(s)
- Mischa T Rijnierse
- Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Joanne A Groeneveldt
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jasmijn S J A van Campen
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Karin de Boer
- Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Cathelijne E E van der Bruggen
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Hendrik J Harms
- Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pieter G Raijmakers
- Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Adriaan A Lammertsma
- Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Paul Knaapen
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Harm Jan Bogaard
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Berend E Westerhof
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Medical Biology, Section of Systems Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Anton Vonk Noordegraaf
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Cornelis P Allaart
- Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Frances S de Man
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Maron BA, Leopold JA, Hemnes AR. Metabolic syndrome, neurohumoral modulation, and pulmonary arterial hypertension. Br J Pharmacol 2020; 177:1457-1471. [PMID: 31881099 DOI: 10.1111/bph.14968] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/03/2019] [Accepted: 12/09/2019] [Indexed: 12/11/2022] Open
Abstract
Pulmonary vascular disease, including pulmonary arterial hypertension (PAH), is increasingly recognized to be affected by systemic alterations including up-regulation of the renin-angiotensin-aldosterone system and perturbations to metabolic pathways, particularly glucose and fat metabolism. There is increasing preclinical and clinical data that each of these pathways can promote pulmonary vascular disease and right heart failure and are not simply disease markers. More recently, trials of therapeutics aimed at neurohormonal activation or metabolic dysfunction are beginning to shed light on how interventions in these pathways may affect patients with PAH. This review will focus on underlying mechanistic data that supports neurohormonal activation and metabolic dysfunction in the pathogenesis of PAH and right heart failure as well as discussing early translational data in patients with PAH.
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Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jane A Leopold
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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29
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Affiliation(s)
- Takeshi Ogo
- From the Division of Pulmonary Circulation, Department of Cardiovascular Medicine and Department of Advanced Medicine for Pulmonary Hypertension, National Cerebral and Cardiovascular Center, Osaka, Japan
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30
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Prins KW, Thenappan T, Weir EK, Kalra R, Pritzker M, Archer SL. Repurposing Medications for Treatment of Pulmonary Arterial Hypertension: What's Old Is New Again. J Am Heart Assoc 2020; 8:e011343. [PMID: 30590974 PMCID: PMC6405714 DOI: 10.1161/jaha.118.011343] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Kurt W Prins
- 1 Cardiovascular Division University of Minnesota Medical School Minneapolis MN
| | - Thenappan Thenappan
- 1 Cardiovascular Division University of Minnesota Medical School Minneapolis MN
| | - E Kenneth Weir
- 1 Cardiovascular Division University of Minnesota Medical School Minneapolis MN
| | - Rajat Kalra
- 1 Cardiovascular Division University of Minnesota Medical School Minneapolis MN
| | - Marc Pritzker
- 1 Cardiovascular Division University of Minnesota Medical School Minneapolis MN
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31
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Oliveira AC, Richards EM, Raizada MK. Pulmonary hypertension: Pathophysiology beyond the lung. Pharmacol Res 2020; 151:104518. [PMID: 31730803 PMCID: PMC6981289 DOI: 10.1016/j.phrs.2019.104518] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 10/25/2019] [Accepted: 10/29/2019] [Indexed: 12/11/2022]
Abstract
Pulmonary hypertension (PH) is classically considered a disease of pulmonary vasculature which has been the predominant target for drug development and PH therapy. Despite significant advancement in recent years in identification of new drug targets and innovative treatment strategies, the prognosis of PH remains poor, with median survival of 5 years. Recent studies have demonstrated involvement of neuroinflammation, altered autonomic and gastrointestinal functions and increased trafficking of bone marrow-derived cells in cardiopulmonary pathophysiology. This has led to the proposal that PH could be considered a systemic disease involving complex interactions among many organs. Our objectives in this review is to summarize evidence for the involvement of the brain, bone marrow and gut in PH pathophysiology. Then, to synthesize all evidence supporting a brain-gut-lung interaction hypothesis for consideration in PH pathophysiology and finally to summarize unanswered questions and future directions to move this novel concept forward. This forward-thinking view, if proven by further experiments, would provide new opportunities and novel targets for the control and treatment of PH.
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Affiliation(s)
- Aline C Oliveira
- Department of Physiology and Functional Genomics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Elaine M Richards
- Department of Physiology and Functional Genomics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Mohan K Raizada
- Department of Physiology and Functional Genomics, College of Medicine, University of Florida, Gainesville, FL 32610, USA.
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Kang J, Lim DH, Kim GH. Hyponatremia Associated with Pulmonary Arterial Hypertension: Syndrome of Inappropriate Antidiuresis Versus Right Heart Failure. Electrolyte Blood Press 2020; 18:40-43. [PMID: 33408746 PMCID: PMC7781766 DOI: 10.5049/ebp.2020.18.2.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/05/2020] [Accepted: 12/05/2020] [Indexed: 11/16/2022] Open
Abstract
Because it is associated with mortality, hyponatremia is an important feature of pulmonary arterial hypertension. Its mechanisms remain unclear, although right heart failure resulting from pulmonary arterial hypertension may lead to systemic congestion and arterial underfilling. However, most patients with pulmonary arterial hypertension are clinically euvolemic and have no peripheral edema. Unlike patients with underlying heart disease, neurohumoral activation is not demonstrated in hyponatremic patients with pulmonary arterial hypertension, who show features of congestive heart failure only at later stages in their disease. Here, a case vignette is introduced, and the pathophysiology of hyponatremia in pulmonary arterial hypertension will be discussed. Syndrome of inappropriate antidiuresis (SIAD) appears to underlie hyponatremia in the initial phase of pulmonary arterial hypertension. The mechanisms by which various lung diseases can lead to SIAD remain an enigma.
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Affiliation(s)
- Juyeon Kang
- Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Dae Hyun Lim
- Department of Internal Medicine, National Medical Center, Seoul, Korea
| | - Gheun-Ho Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
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33
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Ntiloudi D, Qanud K, Tomaio JN, Giannakoulas G, Al-Abed Y, Zanos S. Pulmonary arterial hypertension: the case for a bioelectronic treatment. Bioelectron Med 2019; 5:20. [PMID: 32232109 PMCID: PMC7098229 DOI: 10.1186/s42234-019-0036-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/08/2019] [Indexed: 12/16/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease of unknown etiology that progresses to right ventricular failure. It has a complex pathophysiology, which involves an imbalance between vasoconstrictive and vasodilative processes in the pulmonary circulation, pulmonary vasoconstriction, vascular and right ventricular remodeling, systemic inflammation, and autonomic imbalance, with a reduced parasympathetic and increased sympathetic tone. Current pharmacological treatments for PAH include several classes of drugs that target signaling pathways in vascular biology and cardiovascular physiology, but they can have severe unwanted effects and they do not typically stop the progression of the disease. Pulmonary artery denervation has been tested clinically as a method to suppress sympathetic overactivation, however it is a nonspecific and irreversible intervention. Bioelectronic medicine, in particular vagus nerve stimulation (VNS), has been used in cardiovascular disorders like arrhythmias, heart failure and arterial hypertension and could, in principle, be tested as a treatment in PAH. VNS can produce pulmonary vasodilation and renormalize right ventricular function, via activation of pulmonary and cardiac vagal fibers. It can suppress systemic inflammation, via activation of fibers that innervate the spleen. Finally, VNS can gradually restore the balance between parasympathetic and sympathetic tone by regulating autonomic reflexes. Preclinical studies support the feasibility of using VNS in PAH. However, there are challenges with such an approach, arising from the need to affect a relatively small number of relevant vagal fibers, and the potential for unwanted cardiac and noncardiac effects of VNS in this sensitive patient population.
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Affiliation(s)
- Despοina Ntiloudi
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA.,2Department of Cardiology, AHEPA University Hospital, Thessaloniki, Greece
| | - Khaled Qanud
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA
| | - Jacquelyn-Nicole Tomaio
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA
| | | | - Yousef Al-Abed
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA
| | - Stavros Zanos
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA
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Rothman A, Jonas M, Castel D, Tzafriri AR, Traxler H, Shav D, Leon MB, Ben-Yehuda O, Rubin L. Pulmonary artery denervation using catheter-based ultrasonic energy. EUROINTERVENTION 2019; 15:722-730. [PMID: 31062694 DOI: 10.4244/eij-d-18-01082] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
AIMS Pulmonary arterial hypertension is a devastating disease characterised by pulmonary vascular remodelling and right heart failure. Radio-frequency pulmonary artery denervation (PDN) has improved pulmonary haemodynamics in preclinical and early clinical studies; however, denervation depth is limited. High-frequency non-focused ultrasound can deliver energy to the vessel adventitia, sparing the intima and media. We therefore aimed to investigate the feasibility, safety and efficacy of ultrasound PDN. METHODS AND RESULTS Histological examination demonstrated that innervation of human pulmonary arteries is predominantly sympathetic (71%), with >40% of nerves at a depth of >4 mm. Finite element analysis of ultrasound energy distribution and ex vivo studies demonstrated generation of temperatures >47ºC to a depth of 10 mm. In domestic swine, PDN reduced mean pulmonary artery pressure induced by thromboxane A2 in comparison to sham. No adverse events were observed up to 95 days. Histological examination identified structural and immunohistological changes of nerves in PDN-treated animals, with sparing of the intima and media and reduced tyrosine hydroxylase staining 95 days post procedure, indicating persistent alteration of the structure of sympathetic nerves. CONCLUSIONS Ultrasound PDN is safe and effective in the preclinical setting, with energy delivery to a depth that would permit targeting sympathetic nerves in humans.
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Affiliation(s)
- Alex Rothman
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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Hyponatremia is associated with poor prognosis among patients with chest pain discharged from internal medicine wards following acute coronary syndrome-rule-out. Coron Artery Dis 2019; 31:147-151. [PMID: 31567372 DOI: 10.1097/mca.0000000000000786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hyponatremia is the most common electrolyte abnormality observed in clinical practice. Among patients with acute coronary syndrome (ACS), serum sodium levels are inversely associated with mortality risk. We assessed associations of serum sodium level with ACS and mortality in patients with chest pain. METHODS This retrospective cohort study used clinical data from a large, academic hospital. All adults admitted with chest pain and without hypernatremia and discharged after ACS rule-out from January 2010 through June 2016 were included. The primary endpoint was the composite of 30-day ACS and mortality. Secondary endpoints were a hospital admission due to ACS and mortality in the first year following discharge. RESULTS Included were 12 315 patients (mean age 58.2 ± 13 years, 60% male). Patients were classified according to the serum sodium (Na) level: hyponatremia, defined as less than 135 mEq/L (n = 289, 2.3%); 140 > Na ≥ 135 mEq/L (n = 8066, 65.5%), and 145 > Na ≥ 140 mEq/L (n = 3960, 32.2%). Patients with serum sodium more than 145 mEq/L were excluded. Among patients with hyponatremia, low-normal, and high-normal levels, rates of the composite outcome of unadjusted 30-day all-cause mortality and ACS admission were 4.5, 1.0, and 0.7%, respectively (P < 0.001). Unadjusted one-year ACS rates were 3.8, 1.5, and 1.4%, respectively (P < 0.01). CONCLUSION Hyponatremia is associated with higher mortality and ACS risk among patients with chest pain who were discharged from internal medicine wards following ACS-rule-out. Sodium level may be included in the risk stratification of patients with chest pain.
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Abstract
PURPOSE OF REVIEW Right ventricular (RV) function is an important determinant of morbidity and mortality in patients with pulmonary arterial hypertension (PAH). Although substantial progress has been made in understanding the development of RV failure in the last decennia, this has not yet resulted in the development of RV selective therapies. In this review, we will discuss the current status on the treatment of RV failure and potential novel therapeutic strategies that are currently being investigated in clinical trials. RECENT FINDINGS Increased afterload results in elevated wall tension. Consequences of increased wall tension include autonomic disbalance, metabolic shift and inflammation, negatively affecting RV contractility. Compromised RV systolic function and low cardiac output activate renin-angiotensin aldosterone system, which leads to fluid retention and further increase in RV wall tension. This vicious circle can be interrupted by directly targeting the determinants of RV wall tension; preload and afterload by PAH-medications and diuretics, but is also possibly by restoring neurohormonal and metabolic disbalance, and inhibiting maladaptive inflammation. A variety of RV selective drugs are currently being studied in clinical trials. SUMMARY Nowadays, afterload reduction is still the cornerstone in treatment of PAH. New treatments targeting important pathobiological determinants of RV failure directly are emerging.
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Affiliation(s)
- Joanne A. Groeneveldt
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam
| | - Frances S. de Man
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam
| | - Berend E. Westerhof
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam
- Section of Systems Physiology, Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Heart Rhythm Complexity Impairment in Patients with Pulmonary Hypertension. Sci Rep 2019; 9:10710. [PMID: 31341216 PMCID: PMC6656770 DOI: 10.1038/s41598-019-47144-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 07/09/2019] [Indexed: 12/17/2022] Open
Abstract
Pulmonary hypertension is a fatal disease, however reliable prognostic tools are lacking. Heart rhythm complexity analysis is derived from non-linear heart rate variability (HRV) analysis and has shown excellent performance in predicting clinical outcomes in several cardiovascular diseases. However, heart rhythm complexity has not previously been studied in pulmonary hypertension patients. We prospectively analyzed 57 patients with pulmonary hypertension (31 with pulmonary arterial hypertension and 26 with chronic thromboembolic pulmonary hypertension) and compared them to 57 age- and sex-matched control subjects. Heart rhythm complexity including detrended fluctuation analysis (DFA) and multiscale entropy (MSE) and linear HRV parameters were analyzed. The patients with pulmonary hypertension had significantly lower mean RR, SDRR, pNN20, VLF, LF, LF/HF ratio, DFAα1, MSE slope 5, scale 5, area 1-5 and area 6-20 compared to the controls. Receiver operating characteristic curve analysis showed that heart rhythm complexity parameters were better than traditional HRV parameters to predict pulmonary hypertension. Among all parameters, scale 5 had the greatest power to differentiate the pulmonary hypertension patients from controls (AUC: 0.845, P < 0.001). Furthermore, adding heart rhythm complexity parameters significantly improved the discriminatory power of the traditional HRV parameters in both net reclassification improvement and integrated discrimination improvement models. In conclusion, the patients with pulmonary hypertension had worse heart rhythm complexity. MSE parameters, especially scale 5, had excellent single discriminatory power to predict whether or not patients had pulmonary hypertension.
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Singh I, Rahaghi FN, Naeije R, Oliveira RKF, Vanderpool RR, Waxman AB, Systrom DM. Dynamic right ventricular-pulmonary arterial uncoupling during maximum incremental exercise in exercise pulmonary hypertension and pulmonary arterial hypertension. Pulm Circ 2019; 9:2045894019862435. [PMID: 31218910 PMCID: PMC6643191 DOI: 10.1177/2045894019862435] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Despite recent advances, the prognosis of pulmonary hypertension (PH) remains poor. While the initial insult in PH implicates the pulmonary vasculature, the functional state, exercise capacity, and survival of such patients are closely linked to right ventricular (RV) function. In the current study, we sought to investigate the effects of maximum incremental exercise on the matching of RV contractility and afterload (i.e. right ventricular-pulmonary arterial [RV-PA] coupling) in patients with exercise PH (ePH) and pulmonary arterial hypertension (PAH). End-systolic elastance (Ees), pulmonary arterial elastance (Ea), and RV-PA coupling (Ees/Ea) were determined using single-beat pressure-volume loop analysis in 40 patients that underwent maximum invasive cardiopulmonary exercise testing. Eleven patients had ePH, nine had PAH, and 20 were age-matched controls. During exercise, the impaired exertional contractile reserve in PAH was associated with blunted stroke volume index (SVI) augmentation and reduced peak oxygen consumption (peak VO2 %predicted). Compared to PAH, ePH demonstrated increased RV contractility in response to increasing RV afterload during exercise; however, this was insufficient and resulted in reduced peak RV-PA coupling. The dynamic RV-PA uncoupling in ePH was associated with similarly blunted SVI augmentation and peak VO2 as PAH. In conclusion, dynamic rest-to-peak exercise RV-PA uncoupling during maximum exercise blunts SV increase and reduces exercise capacity in exercise PH and PAH. In ePH, the insufficient increase in RV contractility to compensate for increasing RV afterload during maximum exercise leads to deterioration of RV-PA coupling. These data provide evidence that even in the early stages of PH, RV function is compromised.
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Affiliation(s)
- Inderjit Singh
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Farbod N Rahaghi
- 2 Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Robert Naeije
- 3 Department of Pathophysiology, Erasmsus Campus, Brussels, Belgium
| | - Rudolf K F Oliveira
- 4 Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo - UNIFESP, São Paulo, Brazil
| | | | - Aaron B Waxman
- 2 Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - David M Systrom
- 2 Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Zhang M, Zhang Y, Pang W, Zhai Z, Wang C. Circulating biomarkers in chronic thromboembolic pulmonary hypertension. Pulm Circ 2019; 9:2045894019844480. [PMID: 30942132 PMCID: PMC6552358 DOI: 10.1177/2045894019844480] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious condition characterized with chronic organized thrombi that obstruct the pulmonary vessels, leading to pulmonary hypertension (PH) and ultimately right heart failure. Although CTEPH is the only form of PH that can be cured with surgical intervention, not all patients with CTEPH will be deemed operable. Some CTEPH patients still have a poor prognosis. Therefore, the determination of diagnostic and prognostic biomarkers of CTEPH is of great importance for the early intervention to improve prognosis of patients with CTEPH. Several markers related to multiple mechanisms of CTEPH have been recently identified as circulating diagnostic and prognostic biomarkers in these patients. However, the existing literature review of biomarkers of CTEPH is relatively sparse. In this article, we review recent advances in circulating biomarkers of CTEPH and describe future applications of these biomarkers in the management of CTEPH.
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Affiliation(s)
- Meng Zhang
- 1 Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.,2 Department of Respiratory and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,3 Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,4 National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Yunxia Zhang
- 2 Department of Respiratory and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,3 Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,4 National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Wenyi Pang
- 2 Department of Respiratory and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,3 Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,4 National Clinical Research Center for Respiratory Diseases, Beijing, China.,5 Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhenguo Zhai
- 2 Department of Respiratory and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,3 Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,4 National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Chen Wang
- 1 Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.,2 Department of Respiratory and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,3 Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,4 National Clinical Research Center for Respiratory Diseases, Beijing, China.,5 Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Affiliation(s)
- Anna R Hemnes
- Division of Allergy, Pulmonary, and Critical Care Medicine (A.R.H.)
| | - Evan L Brittain
- Division of Cardiovascular Medicine (E.L.B.), Vanderbilt University Medical Center, Nashville, TN
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Naranjo M, Lo KB, Mezue K, Rangaswami J. Effects of Pulmonary Hypertension and Right Ventricular Function in Short and Long-Term Kidney Function. Curr Cardiol Rev 2019; 15:3-11. [PMID: 30306876 PMCID: PMC6367698 DOI: 10.2174/1573403x14666181008154215] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 09/22/2018] [Accepted: 09/30/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Pulmonary hypertension is not uncommon in patients with renal disease and vice versa; therefore, it influences treatments and outcomes. There is a large body of literature on pulmonary hypertension in patients with kidney disease, its prognostic implications, economic burden, and management strategies. However, the converse, namely the hemodynamic effects of pulmonary hypertension on kidney function (acute and chronic kidney injury) is less studied and described. There is also increasing interest in the effects of pulmonary hypertension on kidney transplant outcomes. The relationship is a complex phenomenon and multiple body systems and mechanisms are involved in its pathophysiology. Although the definition of pulmonary hypertension has evolved over time with the understanding of multiple interplays between the heart, lungs, kidneys, etc; there is limited evidence to provide a specific treatment strategy when kidneys and lungs are affected at the same time. Nevertheless, available evidence appears to support new therapeutics and highlights the importance of individualized approach. There is sufficient research showing that the morbidity and mortality from PH are driven by the influence of the pulmonary hemodynamic dysfunction on the kidneys. CONCLUSION This concise review focuses on the effects of pulmonary hypertension on the kidneys, including, the patho-physiological effects of pulmonary hypertension on acute kidney injury, progression of CKD, effects on kidney transplant outcomes, progression of kidney disease in situations such as post LVAD implantation and novel diagnostic indices. We believe a review of this nature will fill in an important gap in understanding the prognostic implication of pulmonary hypertension on renal disease, and help highlight this important component of the cardio-reno-pulmonary axis.
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Affiliation(s)
- Mario Naranjo
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, United States
| | - Kevin Bryan Lo
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, United States
| | - Kenechukwu Mezue
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, United States
| | - Janani Rangaswami
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, United States.,Sidney Kimmel College of Thomas Jefferson University, Philadelphia, PA, United States
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Cirulis MM, Ryan JJ, Archer SL. Pathophysiology, incidence, management, and consequences of cardiac arrhythmia in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Pulm Circ 2019; 9:2045894019834890. [PMID: 30747032 PMCID: PMC6410395 DOI: 10.1177/2045894019834890] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Arrhythmias are increasingly recognized as serious, end-stage complications of pre-capillary pulmonary hypertension, including pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). Although arrhythmias contribute to symptoms, morbidity, in-hospital mortality, and possibly sudden death in PAH/CTEPH, there remains a paucity of epidemiologic, pathophysiologic, and outcome data to guide management of these patients. This review summarizes the most current evidence on the topic: from the molecular mechanisms driving arrhythmia in the hypertrophied or failing right heart, to the clinical aspects of epidemiology, diagnosis, and management.
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Affiliation(s)
- Meghan M Cirulis
- 1 Division of Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA
- 2 Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - John J Ryan
- 2 Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Stephen L Archer
- 3 Department of Medicine, Queen's University, Kingston, ON, Canada
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Viswanathan G, Mamazhakypov A, Schermuly RT, Rajagopal S. The Role of G Protein-Coupled Receptors in the Right Ventricle in Pulmonary Hypertension. Front Cardiovasc Med 2018; 5:179. [PMID: 30619886 PMCID: PMC6305072 DOI: 10.3389/fcvm.2018.00179] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/30/2018] [Indexed: 12/14/2022] Open
Abstract
Pressure overload of the right ventricle (RV) in pulmonary arterial hypertension (PAH) leads to RV remodeling and failure, an important determinant of outcome in patients with PAH. Several G protein-coupled receptors (GPCRs) are differentially regulated in the RV myocardium, contributing to the pathogenesis of RV adverse remodeling and dysfunction. Many pharmacological agents that target GPCRs have been demonstrated to result in beneficial effects on left ventricular (LV) failure, such as beta-adrenergic receptor and angiotensin receptor antagonists. However, the role of such drugs on RV remodeling and performance is not known at this time. Moreover, many of these same receptors are also expressed in the pulmonary vasculature, which could result in complex effects in PAH. This manuscript reviews the role of GPCRs in the RV remodeling and dysfunction and discusses activating and blocking GPCR signaling to potentially attenuate remodeling while promoting improvements of RV function in PAH.
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Affiliation(s)
- Gayathri Viswanathan
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Argen Mamazhakypov
- Department of Internal Medicine, Member of the German Center for Lung Research (DZL), Justus Liebig University of Giessen, Giessen, Germany
| | - Ralph T Schermuly
- Department of Internal Medicine, Member of the German Center for Lung Research (DZL), Justus Liebig University of Giessen, Giessen, Germany
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, United States
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Yoshida K, Saku K, Kamada K, Abe K, Tanaka-Ishikawa M, Tohyama T, Nishikawa T, Kishi T, Sunagawa K, Tsutsui H. Electrical Vagal Nerve Stimulation Ameliorates Pulmonary Vascular Remodeling and Improves Survival in Rats With Severe Pulmonary Arterial Hypertension. ACTA ACUST UNITED AC 2018; 3:657-671. [PMID: 30456337 PMCID: PMC6234524 DOI: 10.1016/j.jacbts.2018.07.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/25/2018] [Accepted: 07/30/2018] [Indexed: 11/29/2022]
Abstract
Autonomic imbalance has been documented in patients with PAH. Electrical VNS is known to restore autonomic balance and improve heart failure. This study aimed to elucidate the therapeutic effects of VNS on severe PAH in a rat model. VNS significantly restored autonomic balance, decreased mean pulmonary arterial pressure, attenuated pulmonary vascular remodeling, and preserved right ventricular function. In addition, VNS markedly improved the survival of rats with PAH. Our findings may contribute greatly to the development of device therapy for PAH and widen the clinical applicability of VNS.
This study aimed to elucidate the therapeutic effects of electrical vagal nerve stimulation (VNS) on severe pulmonary arterial hypertension in a rat model. In a pathophysiological study, VNS significantly restored autonomic balance, decreased mean pulmonary arterial pressure, attenuated pulmonary vascular remodeling, and preserved right ventricular function. In a survival study, VNS significantly improved the survival rate in both the prevention (VNS from 0 to 5 weeks after a SU5416 injection) and treatment (VNS from 5 to 10 weeks) protocols. Thus, VNS may serve as a novel therapeutic strategy for pulmonary arterial hypertension.
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Key Words
- BNP, brain natriuretic peptide
- HF, high-frequency
- HRV, heart rate variability
- IL, interleukin
- MCP, monocyte chemotactic protein
- NE, norepinephrine
- NO, nitric oxide
- PA, pulmonary artery
- PAH, pulmonary arterial hypertension
- PAP, pulmonary arterial pressure
- PVR, pulmonary vascular resistance
- RV, right ventricular
- RVEDP, right ventricular end-diastolic pressure
- SS, sham-stimulated
- VNS, vagal nerve stimulation
- autonomic imbalance
- eNOS, endothelial nitric oxide synthase
- mRNA, messenger ribonucleic acid
- pulmonary arterial hypertension
- pulmonary vascular remodeling
- vagal nerve stimulation
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Affiliation(s)
- Keimei Yoshida
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Keita Saku
- Department of Advanced Risk Stratification for Cardiovascular Diseases, Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan
- Address for correspondence: Dr. Keita Saku, Department of Advanced Risk Stratification for Cardiovascular Diseases, Center for Disruptive Cardiovascular Medicine, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Kazuhiro Kamada
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kohtaro Abe
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Mariko Tanaka-Ishikawa
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takeshi Tohyama
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takuya Nishikawa
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takuya Kishi
- Department of Advanced Risk Stratification for Cardiovascular Diseases, Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan
| | - Kenji Sunagawa
- Department of Therapeutic Regulation of Cardiovascular Homeostasis, Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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Luna RCP, de Oliveira Y, Lisboa JVC, Chaves TR, de Araújo TAM, de Sousa EE, Miranda Neto M, Pirola L, Braga VA, de Brito Alves JL. Insights on the epigenetic mechanisms underlying pulmonary arterial hypertension. ACTA ACUST UNITED AC 2018; 51:e7437. [PMID: 30365723 PMCID: PMC6207290 DOI: 10.1590/1414-431x20187437] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 09/04/2018] [Indexed: 12/21/2022]
Abstract
Pulmonary arterial hypertension (PAH), characterized by localized increased
arterial blood pressure in the lungs, is a slow developing long-term disease
that can be fatal. PAH is characterized by inflammation, vascular tone
imbalance, pathological pulmonary vascular remodeling, and right-sided heart
failure. Current treatments for PAH are palliative and development of new
therapies is necessary. Recent and relevant studies have demonstrated that
epigenetic processes may exert key influences on the pathogenesis of PAH and may
be promising therapeutic targets in the prevention and/or cure of this
condition. The aim of the present mini-review is to summarize the occurrence of
epigenetic-based mechanisms in the context of PAH physiopathology, focusing on
the roles of DNA methylation, histone post-translational modifications and
non-coding RNAs. We also discuss the potential of epigenetic-based therapies for
PAH.
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Affiliation(s)
- R C P Luna
- Departamento de Nutrição, Centro de Ciências da Saúde, Universidade Federal da Paraíba, João Pessoa, PB, Brasil
| | - Y de Oliveira
- Departamento de Nutrição, Centro de Ciências da Saúde, Universidade Federal da Paraíba, João Pessoa, PB, Brasil
| | - J V C Lisboa
- Departamento de Nutrição, Centro de Ciências da Saúde, Universidade Federal da Paraíba, João Pessoa, PB, Brasil
| | - T R Chaves
- Departamento de Nutrição, Centro de Ciências da Saúde, Universidade Federal da Paraíba, João Pessoa, PB, Brasil
| | - T A M de Araújo
- Departamento de Nutrição, Centro de Ciências da Saúde, Universidade Federal da Paraíba, João Pessoa, PB, Brasil
| | - E E de Sousa
- Departamento de Nutrição, Centro de Ciências da Saúde, Universidade Federal da Paraíba, João Pessoa, PB, Brasil
| | - M Miranda Neto
- Departamento de Nutrição, Centro de Ciências da Saúde, Universidade Federal da Paraíba, João Pessoa, PB, Brasil
| | - L Pirola
- INSERM U1060, Lyon 1 University, Oullins, France
| | - V A Braga
- Departamento de Biotecnologia, Centro de Biotecnologia, Universidade Federal da Paraíba, João Pessoa, PB, Brasil
| | - J L de Brito Alves
- Departamento de Nutrição, Centro de Ciências da Saúde, Universidade Federal da Paraíba, João Pessoa, PB, Brasil.,Departamento de Biotecnologia, Centro de Biotecnologia, Universidade Federal da Paraíba, João Pessoa, PB, Brasil
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46
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Marra AM, Bossone E, Salzano A, D’Assante R, Monaco F, Ferrara F, Arcopinto M, Vriz O, Suzuki T, Cittadini A. Biomarkers in Pulmonary Hypertension. Heart Fail Clin 2018; 14:393-402. [DOI: 10.1016/j.hfc.2018.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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48
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Bansal S, Prasad A, Linas S. Right Heart Failure-Unrecognized Cause of Cardiorenal Syndrome. J Am Soc Nephrol 2018; 29:1795-1798. [PMID: 29764920 DOI: 10.1681/asn.2018020224] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Shweta Bansal
- Divisions of Nephrology and .,Renal Section, South Texas Veterans Healthcare System, San Antonio, Texas
| | - Anand Prasad
- Cardiology, University of Texas Health at San Antonio, San Antonio, Texas
| | - Stuart Linas
- Renal and Hypertension Division, University of Colorado School of Medicine, Aurora, Colorado; and.,Nephrology Division, Denver Health Medical Center, Denver, Colorado
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49
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Physiological insights of exercise hyperventilation in arterial and chronic thromboembolic pulmonary hypertension. Int J Cardiol 2018; 259:178-182. [DOI: 10.1016/j.ijcard.2017.11.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 10/17/2017] [Accepted: 11/08/2017] [Indexed: 11/21/2022]
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50
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Serum Chloride Levels Track With Survival in Patients With Pulmonary Arterial Hypertension. Chest 2018; 154:541-549. [PMID: 29698719 DOI: 10.1016/j.chest.2018.04.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/16/2018] [Accepted: 04/02/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Serum chloride is an important homeostatic biomarker in left heart failure, with significant prognostic implications. The impact of serum chloride in the long-term survival of patients with pulmonary arterial hypertension (PAH) is unknown. We tested whether serum chloride levels are associated with long-term survival in patients with PAH. METHODS We included patients with idiopathic or heritable PAH who had a basic metabolic panel performed at the time of their diagnostic right heart catheterization. Laboratory results were recorded both at diagnosis and 6-month follow-up. RESULTS We included 277 patients, mean age 51 ± 18 years and 73% women, of whom 254 had a follow-up electrolyte determination at 6 months. Serum chloride was 102.9 ± 3.9 mM/L at diagnosis. A serum chloride ≤ 100 mM/L was noted in 65 (24%) and 53 (21%) patients at diagnosis and 6 months, respectively. Patients with serum chloride ≤ 100 mM/L at 6 months tracked with increase mortality when adjusted by age, sex, pulmonary vascular resistance, diuretics or prostacyclin analogs usage, and serum creatinine and sodium at 6 months (hazard ratio, 1.83; 95% CI, 1.11-3.00). This group of patients was older, with decreased functional capacity, had worse renal function, took more diuretics, had higher pulmonary artery wedge pressure but lower mean pulmonary artery pressure, transpulmonary gradient, and pulmonary vascular resistance. CONCLUSIONS Serum chloride at 6 months from the PAH diagnosis is a strong and independent predictor of mortality in patients with idiopathic or heritable PAH, even after adjusting serum sodium, renal function, diuretic, and prostacyclin analog usage.
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