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Kadoglou NPE, Khattab E, Velidakis N, Gkougkoudi E, Myrianthefs MM. The Role of Echocardiography in the Diagnosis and Prognosis of Pulmonary Hypertension. J Pers Med 2024; 14:474. [PMID: 38793056 PMCID: PMC11122427 DOI: 10.3390/jpm14050474] [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: 03/15/2024] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/26/2024] Open
Abstract
The right heart catheterisation constitutes the gold standard for pulmonary hypertension (PH) diagnosis. However, echocardiography remains a reliable, non-invasive, inexpensive, convenient, and easily reproducible modality not only for the preliminary screening of PH but also for PH prognosis. The aim of this review is to describe a cluster of echocardiographic parameters for the detection and prognosis of PH and analyse the challenges of echocardiography implementation in patients with suspected or established PH. The most important echocardiographic index is the calculation of pulmonary arterial systolic pressure (PASP) through the tricuspid regurgitation (TR). It has shown high correlation with invasive measurement of pulmonary pressure, but several drawbacks have questioned its accuracy. Besides this, the right ventricular outflow track acceleration time (RVOT-AT) has been proposed for PH diagnosis. A plethora of echocardiographic indices: right atrial area, pericardial effusion, the tricuspid annular plane systolic excursion (TAPSE), the TAPSE/PASP ratio, tricuspid annular systolic velocity (s'), can reflect the severity and prognosis of PH. Recent advances in echocardiography with 3-dimensional right ventricular (RV) ejection fraction, RV free wall strain and right atrial strain may further assist the prognosis of PH.
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Affiliation(s)
- Nikolaos P. E. Kadoglou
- Medical School, University of Cyprus, 215/6 Old Road Lefkosias-Lemesou, Aglatzia, Nicosia 2029, Cyprus; (E.K.); (N.V.); (E.G.)
- Cardiology Department, Nicosia General Hospital, Lemesou 215, Strovolos, Nicosia 2029, Cyprus;
| | - Elina Khattab
- Medical School, University of Cyprus, 215/6 Old Road Lefkosias-Lemesou, Aglatzia, Nicosia 2029, Cyprus; (E.K.); (N.V.); (E.G.)
- Cardiology Department, Nicosia General Hospital, Lemesou 215, Strovolos, Nicosia 2029, Cyprus;
| | - Nikolaos Velidakis
- Medical School, University of Cyprus, 215/6 Old Road Lefkosias-Lemesou, Aglatzia, Nicosia 2029, Cyprus; (E.K.); (N.V.); (E.G.)
| | - Evaggelia Gkougkoudi
- Medical School, University of Cyprus, 215/6 Old Road Lefkosias-Lemesou, Aglatzia, Nicosia 2029, Cyprus; (E.K.); (N.V.); (E.G.)
| | - Michael M. Myrianthefs
- Cardiology Department, Nicosia General Hospital, Lemesou 215, Strovolos, Nicosia 2029, Cyprus;
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Mattei A, Strumia A, Benedetto M, Nenna A, Schiavoni L, Barbato R, Mastroianni C, Giacinto O, Lusini M, Chello M, Carassiti M. Perioperative Right Ventricular Dysfunction and Abnormalities of the Tricuspid Valve Apparatus in Patients Undergoing Cardiac Surgery. J Clin Med 2023; 12:7152. [PMID: 38002763 PMCID: PMC10672350 DOI: 10.3390/jcm12227152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/03/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
Right ventricular (RV) dysfunction frequently occurs after cardiac surgery and is linked to adverse postoperative outcomes, including mortality, reintubation, stroke, and prolonged ICU stays. While various criteria using echocardiography and hemodynamic parameters have been proposed, a consensus remains elusive. Distinctive RV anatomical features include its thin wall, which presents a triangular shape in a lateral view and a crescent shape in a cross-sectional view. Principal causes of RV dysfunction after cardiac surgery encompass ischemic reperfusion injury, prolonged ischemic time, choice of cardioplegia and its administration, cardiopulmonary bypass weaning characteristics, and preoperative risk factors. Post-left ventricular assist device (LVAD) implantation RV dysfunction is common but often transient, with a favorable prognosis upon resolution. There is an ongoing debate regarding the benefits of concomitant surgical repair of the RV in the presence of regurgitation. According to the literature, the gold standard techniques for assessing RV function are cardiac magnetic resonance imaging and hemodynamic assessment using thermodilution. Echocardiography is widely favored for perioperative RV function evaluation due to its accessibility, reproducibility, non-invasiveness, and cost-effectiveness. Although other techniques exist for RV function assessment, they are less common in clinical practice. Clinical management strategies focus on early detection and include intravenous drugs (inotropes and vasodilators), inhalation drugs (pulmonary vasodilators), ventilator strategies, volume management, and mechanical support. Bridging research gaps in this field is crucial to improving clinical outcomes associated with RV dysfunction in the near future.
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Affiliation(s)
- Alessia Mattei
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Alessandro Strumia
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Maria Benedetto
- Cardio-Thoracic and Vascular Anesthesia and Intesive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40123 Bologna, Italy;
| | - Antonio Nenna
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Lorenzo Schiavoni
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Raffaele Barbato
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Ciro Mastroianni
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Omar Giacinto
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Mario Lusini
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Massimo Chello
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Massimiliano Carassiti
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
- Anesthesia and Intensive Care Research Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
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Xu J, Desmond EL, Wong TC, Neill CG, Simon MA, Brigham JC. Right Ventricular Shape Feature Quantification for Evaluation of Pulmonary Hypertension: Feasibility and Preliminary Associations With Clinical Outcome Submitted for Publication. J Biomech Eng 2022; 144:1120496. [PMID: 34549255 DOI: 10.1115/1.4052495] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Indexed: 11/08/2022]
Abstract
This study aimed to demonstrate feasibility of statistical shape analysis techniques to identify distinguishing features of right ventricle (RV) shape as related to hemodynamic variables and outcome data in pulmonary hypertension (PH). Cardiovascular magnetic resonance images were acquired from 50 patients (33 PH, 17 non-PH). Contemporaneous right heart catheterization data were collected for all individuals. Outcome was defined by all-cause mortality and hospitalization for heart failure. RV endocardial borders were manually segmented, and three-dimensional surfaces reconstructed at end diastole and end systole. Registration and harmonic mapping were then used to create a quantitative correspondence between all RV surfaces. Proper orthogonal decomposition was performed to generate modes describing RV shape features. The first 15 modes captured over 98% of the total modal energy. Two shape modes, 8 (free wall expansion) and 13 (septal flattening), stood out as relating to PH state (mode 13: r = 0.424, p = 0.002; mode 8: r = 0.429, p = 0.002). Mode 13 was significantly correlated with outcome (r = 0.438, p = 0.001), more so than any hemodynamic variable. Shape analysis techniques can derive unique RV shape descriptors corresponding to specific, anatomically meaningful features. The modes quantify shape features that had been previously only qualitatively related to PH progression. Modes describing relevant RV features are shown to correlate with clinical measures of RV status, as well as outcomes. These new shape descriptors lay the groundwork for a noninvasive strategy for identification of failing RVs, beyond what is currently available to clinicians.
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Affiliation(s)
- Jing Xu
- Department of Civil and Environmental Engineering, University of Pittsburgh, Pittsburgh, PA 15261
| | | | - Timothy C Wong
- Department of Medicine, Division of Cardiology, University of Pittsburgh School of Medicine Cardiovascular Magnetic Resonance Center, UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15213
| | - Colin G Neill
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37240
| | - Marc A Simon
- Department of Medicine/Division of Cardiology, University of California, San Francisco, CA 94143
| | - John C Brigham
- Department of Civil and Environmental Engineering, University of Pittsburgh, Pittsburgh, PA 15261
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Michalski TA, Pszczola J, Lisowska A, Knapp M, Sobkowicz B, Kaminski K, Ptaszynska-Kopczynska K. ECG in the clinical and prognostic evaluation of patients with pulmonary arterial hypertension: an underestimated value. Ther Adv Respir Dis 2022; 16:17534666221087846. [PMID: 35442108 PMCID: PMC9024159 DOI: 10.1177/17534666221087846] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a rare disease leading to right ventricular (RV) failure and manifests in decreasing exercise tolerance. Our study aimed to assess the usefulness of electrocardiographic parameters reflecting right heart hypertrophy as predictors of clinical status in PAH. METHODS The retrospective analysis included 26 patients, mean 49 ± 17 years of age, diagnosed with PAH, and eligible to undergo cardiopulmonary exercise test (CPET). The relations between ECG values and parameters obtained in procedures such as six-minute walk test (6-MWT), echocardiography, right heart catheterization (RHC), and CPET were analyzed. RESULTS P-wave amplitude in lead II correlated positively with CPET parameter of respiratory response: minute ventilation to carbon dioxide production slope (VE/VCO2 slope; r = 0.436, p = 0.029) and echocardiographic estimated RA pressure (RAP; r = 0.504, p = 0.02). RV Sokolow-Lyon index (RVSLI) positively correlated with echocardiographic parameters reflecting RV function, overload, and afterload-tricuspid regurgitation pressure gradient (TRPG; r = 0.788, p < 0.001), RV free wall thickness (r = 0.738, p < 0.001), and mean pulmonary arterial pressure (mPAPECHO; r = 0.62, p = 0.0016), respectively, as well as VE/VCO2 slope (r = 0.593, p = 0.001) and mPAP assessed directly in RHC (mPAPRHC; r = 0.469, p = 0.0497). R-wave in lead aVR correlated positively with TRPG (r = 0.719, p < 0.001), mPAPECHO (r = 0.446, p = 0.033), and several hemodynamic criteria of PAH diagnosis: positively with mPAPRHC (r = 0.505, p = 0.033) and pulmonary vascular resistance (r = 0.554, p = 0.026) and negatively with pulmonary capillary wedge pressure (r = -0.646, p = 0.004). QRS duration correlated positively with estimated RAP (r = 0.589, p = 0.004), vena cava inferior diameter (r = 0.506, p = 0.016), and RA area (r = 0.679, p = 0.002) and negatively with parameters of exercise capacity: peak VO2 (r = -0.486, p = 0.012), CPET maximum load (r = - 0.439, p = 0.025), and 6-MWT distance (r = -0.430, p = 0.046). ROC curves to detect intermediate/high 1-year mortality risk (based on ESC criteria) indicate RVSLI (cut-off point: 1.57 mV, AUC: 0.771) and QRS duration (cut-off points: 0.09 s, AUC: 703 and 0.1 s, AUC: 0.759) as relevant predictors. CONCLUSION Electrocardiography appears to be an important and underappreciated tool in PAH assessment. ECG corresponds with clinical parameters reflecting PAH severity.
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Affiliation(s)
- Tomasz Adam Michalski
- Students' Scientific Society, Department of Cardiology, Medical University of Bialystok, Bialystok, Poland1st Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Joanna Pszczola
- Students' Scientific Society, Department of Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Anna Lisowska
- Department of Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Malgorzata Knapp
- Department of Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Bozena Sobkowicz
- Department of Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Karol Kaminski
- Department of Cardiology, Medical University of Bialystok, Bialystok, Poland.,Department of Population Medicine and Lifestyle Diseases Prevention, Medical University of Bialystok, Bialystok, Poland
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C. Robertson L, E. Oates K, J. Fletcher A, P. Sylvester K. The association of six-minute walk work and other clinical measures to cardiopulmonary exercise test parameters in pulmonary vascular disease. Pulm Circ 2021; 11:20458940211059055. [PMID: 34917334 PMCID: PMC8670788 DOI: 10.1177/20458940211059055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 10/20/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION In pulmonary vascular disease exercise, abnormalities can include reduced exercise capacity, reduced oxygen pulse and elevated VE/VCO2. The association of clinical measures such as six-minute walk work, haemodynamics, lung function and echocardiogram to peak VO2, O2 pulse and VE/VCO2 has not been fully investigated in pulmonary vascular disease. AIMS To determine the relationship of six-minute walk work and other clinical measures to peak VO2, peak O2 pulse and VE/VCO2. Additionally, to investigate the ability to predict peak VO2 from six-minute walk work and other clinical parameters. METHODS Clinical data was retrospectively analysed from 63 chronic thromboembolic pulmonary hypertension (CTEPH) and 54 chronic thromboembolic disease (CTED) patients. Six-minute walk test measures, haemodynamics, lung function and echocardiographic measures were correlated with peak VO2, peak O2 pulse and VE/VCO2. Predictive equations were developed to predict peak V̇O2 in both CTEPH and CTED cohorts and subsequently validated. RESULTS A number of clinical parameters correlated to peak VO2, peak O2 pulse and VE/VCO2. Six-minute walk work and transfer factor for carbon monoxide demonstrated the strongest correlation to peak VO2 and peak O2 pulse. The validation of the predictive equations showed a variable level of agreement between measured peak VO2 and calculated peak VO2 from the predictive equations. CONCLUSION Six-minute walk work and additionally a number of clinical test parameters were associated to peak VO2, peak O2 pulse and VE/VCO2. Six-minute walk work and transfer factor for carbon monoxide were particularly highly correlated to peak VO2 and similarly to peak oxygen pulse. The validation of the predictive equations showed a variable level of agreement and therefore may have limited clinical applicability.
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Affiliation(s)
- Lucy C. Robertson
- Department of Respiratory Physiology, Royal Papworth Hospital, Royal Papworth Hospital, Cambridge, UK
| | - Katrina E. Oates
- Department of Respiratory Physiology, Royal Papworth Hospital, Royal Papworth Hospital, Cambridge, UK
| | - Andy J. Fletcher
- Department of Cardiac Physiology, Royal Papworth Hospital,
Cambridge, UK
| | - Karl P. Sylvester
- Department of Respiratory Physiology, Royal Papworth Hospital, Royal Papworth Hospital, Cambridge, UK
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Echocardiographic Assessment of Right Ventricular-Arterial Coupling in Predicting Prognosis of Pulmonary Arterial Hypertension Patients. J Clin Med 2021; 10:jcm10132995. [PMID: 34279478 PMCID: PMC8268071 DOI: 10.3390/jcm10132995] [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: 06/22/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 11/23/2022] Open
Abstract
In response to an increased afterload in pulmonary arterial hypertension (PAH), the right ventricle (RV) adapts by remodeling and increasing contractility. The idea of coupling refers to maintaining a relatively constant relationship between ventricular contractility and afterload. Twenty-eight stable PAH patients (mean age 49.5 ± 15.5 years) were enrolled into the study. The follow-up time of this study was 58 months, and the combined endpoint (CEP) was defined as death or clinical deterioration. We used echo TAPSE as a surrogate of RV contractility and estimated systolic pulmonary artery pressure (sPAP) reflecting RV afterload. Ventricular–arterial coupling was evaluated by the ratio between these two parameters (TAPSE/sPAP). In the PAH group, the mean pulmonary artery pressure (mPAP) was 47.29 ± 15.3 mmHg. The mean echo-estimated TAPSE/sPAP was 0.34 ± 0.19 mm/mmHg and was comparable in value and prognostic usefulness to the parameter derived from magnetic resonance and catheterization (ROC analysis). Patients who had CEP (n = 21) had a significantly higher mPAP (53.11 ± 17.11 mmHg vs. 34.86 ± 8.49 mmHg, p = 0.03) and lower TAPSE/sPAP (0.30 ± 0.21 vs. 0.43 ± 0.23, p = 0.04). Patients with a TAPSE/sPAP lower than 0.25 mm/mmHg had worse prognosis, with log-rank test p = 0.001. the echocardiographic estimation of TAPSE/sPAP offers an easy, reliable, non-invasive prognostic parameter for the comprehensive assessment of hemodynamic adaptation in PAH patients.
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Correale M, Monaco I, Ferraretti A, Tricarico L, Sicuranza M, Gallotta AM, Formica ES, Acanfora G, Di Biase M, Brunetti ND. Ventilatory power, a cardiopulmonary exercise testing parameter for the prediction of pulmonary hypertension at right heart catheterization. IJC HEART & VASCULATURE 2020; 28:100513. [PMID: 32346602 PMCID: PMC7178492 DOI: 10.1016/j.ijcha.2020.100513] [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: 03/12/2020] [Revised: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Several cardiopulmonary exercise test (CPET) parameters (peak VO2, PetCO2 and VE/VCO2) emerged as tools for the prediction of pulmonary arterial hypertension (PAH). Less is known on ventilatory power (VP) in patients with suspect PAH. AIM To ascertain possible correlations between VP derived at CPET and hemodynamic parameters at right heart catheterization (RHC) indicative of PH. METHODS Forty-seven consecutive outpatients with suspect of PAH were assessed by CPET and RHC; VP was defined as peak SBP divided by the minute ventilation-CO2 production slope at CPET and Diastolic Pressure Gradient (DPG), Trans-pulmonary Pressure Gradient (TPG), mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) at RHC were also assessed and compared with VP. RESULTS VP values were inversely related to mPAP (r -0.427, p 0.003), DPG (r -0.36, p 0.019), TPG (r: -0.43, p 0.004), and PVR (r -0.52, p 0.001). Correlations remained significant even after correction at multivariate analysis for age and gender. VP values below median identified subjects with mPAP ≥ 25 mmHg with an odds ratio of 4.5 (95% confidence interval 1.05-19.36, p < 0.05), an accuracy of 0.712 at ROC curve analysis (95% confidence interval 0.534-0.852, p < 0.05) and a positive predictive power 82%. CONCLUSIONS In patients with suspected PAH, VP assessed at CPET might provide further information in predicting PAH at RHC. Correlations with PVR and DPG may be helpful in differentiating patients with isolated post-capillary PH from those with combined post-capillary and pre-capillary.
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Key Words
- 6MWT, 6-minute walking test
- BMI, body mass index
- CI, cardiac index
- COPD, chronic obstructive pulmonary disease
- CPET, cardiopulmonary exercise testing
- Cardiopulmonary exercise test
- Cpc-PH, combined post-capillary and pre-capillary pulmonary hypertension
- DPG, diastolic pressure gradient (diastolic PAP – mean PAWP)
- Diastolic pressure gradient
- ECG, electrocardiogram
- EF, ejection fraction
- Ipc-PH, isolated post-capillary pulmonary hypertension
- NYHA, New York Heart Association
- PAH, pulmonary arterial hypertension
- PAWP, pulmonary artery wedge pressure
- PAsP, systolic pulmonary arterial pressure
- PH, pulmonary hypertension
- PVR, pulmonary vascular resistance
- Peak VO2, peak oxygen consumption
- PetCO2, end-tidal carbon dioxide tension
- Pulmonary vascular resistance
- RAP, right atrial pressure
- RHC, right heart catheterization
- RV, right ventricle
- TPG, transpulmonary pressure gradient (mean PAP – mean PAWP)
- Transpulmonary pressure gradient
- VE, ventilation
- VE/VCO2, minute ventilation- carbondioxide production ratio
- VP, ventilatory power
- Ventilatory power
- mPAP, mean pulmonary arterial pressure
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Affiliation(s)
- Michele Correale
- Cardiology Department, Ospedali Riuniti University Hospital, Foggia, Italy
| | - Ilenia Monaco
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
| | - Armando Ferraretti
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
| | - Lucia Tricarico
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
| | - Monica Sicuranza
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
| | - Anna Maria Gallotta
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
| | | | | | - Matteo Di Biase
- Cardiology Department, Ospedali Riuniti University Hospital, Foggia, Italy
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