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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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Zhang A, Ding L, Zhang H, Mi L, Yu F, Tang M. Radiofrequency catheter ablation for pulmonary hypertension patients with atrial flutter. ESC Heart Fail 2024; 11:883-892. [PMID: 38200382 DOI: 10.1002/ehf2.14659] [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: 07/07/2023] [Revised: 11/06/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
AIMS We aimed to evaluate the effects of radiofrequency catheter ablation (RFCA) and the factors influencing mortality after RFCA in patients with pulmonary hypertension (PH) and atrial flutter (AFL). METHODS AND RESULTS Fifty-eight consecutive PH patients with AFL who underwent an electrophysiological study and RFCA between April 2013 and August 2021 were selected for this study. In the study population, pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) was the most common type of PH (n = 34, 59%), followed by idiopathic pulmonary arterial hypertension (IPAH) (n = 19, 33%). Typical atrial flutter was the most common type of atrial flutter (n = 50, 86.2%). Sinus rhythm was restored in 53 (91.4%) patients during RFCA. After a mean follow-up of 33.8 months, AFL recurred in a total of 22 patients. Nine of them underwent repeat RFCA, and the site of the repeat ablation was not exactly the same as the first. At a median follow-up of 34.6 months after the last ablation, none of the patients who underwent repeat RFCA experienced AFL recurrence, and all of these patients survived. There were no procedure-related complications during hospitalization or follow-up. Univariate Cox regression analysis suggested that AFL recurrence after the last ablation was not associated with all-cause mortality. NT-proBNP (HR: 1.00024, 95% CI: 1.00008-1.00041, P = 0.004), pulmonary artery systolic pressure (PASP) (HR: 1.048, 95% CI: 1.020-1.076, P = 0.001), and IPAH (vs. PAH-CHD, HR 7.720, 95% CI: 1.437-41.483, P = 0.017) were independent predictors of all-cause mortality in PH patients with AFL after RFCA. Receiver operating characteristic (ROC) curve analysis revealed that the area under the curve (AUC) of PASP for predicting all-cause mortality was 0.708. There was no significant difference in the Kaplan-Meier curves for all-cause mortality between patients with AFL recurrence after the last ablation and those without recurrence (P = 0.851). Patients with higher PASP (≥110 mmHg) and IPAH showed the lower survival rate in Kaplan-Meier curves. CONCLUSION Repeat ablation was safe and feasible in patients with recurrent AFL and can maintain sinus rhythm. AFL recurrence was not associated with all-cause mortality, and patients with high PASP or IPAH were at higher risk for adverse outcomes.
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Affiliation(s)
- Aikai Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Lei Ding
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Hongda Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Lijie Mi
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Fengyuan Yu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Min Tang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Anand S, Cronin EM. Arrhythmias in Patients with Pulmonary Hypertension and Right Ventricular Failure: Importance of Rhythm Control Strategies. J Clin Med 2024; 13:1866. [PMID: 38610631 PMCID: PMC11012772 DOI: 10.3390/jcm13071866] [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: 02/05/2024] [Revised: 03/14/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024] Open
Abstract
Arrhythmias frequently complicate the course of advanced pulmonary hypertension, often leading to hemodynamic compromise, functional impairment, and mortality. Given the importance of right atrial function in this physiology, the restoration and maintenance of sinus rhythm are of critical importance. In this review, we outline the pathophysiology of arrhythmias and their impact on right heart performance; describe considerations for antiarrhythmic drug selection, anesthetic and periprocedural management; and discuss the results of catheter ablation techniques in this complex and challenging patient population.
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Affiliation(s)
| | - Edmond M. Cronin
- Section of Cardiology, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA;
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Rubens M, Ramamoorthy V, Saxena A, Jimenez J, George S, Baker J, Ruiz J, Chaparro S. Hospital Outcomes in Patients With Pulmonary Hypertension With Atrial Fibrillation in the United States. Am J Cardiol 2024; 212:67-72. [PMID: 38040280 DOI: 10.1016/j.amjcard.2023.11.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/12/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023]
Abstract
In this study, using a large database, we examined the association between atrial fibrillation (AF) in hospitalized patients with pulmonary hypertension (PH) and in-hospital mortality and other adverse hospital outcomes. This study was a retrospective analysis of the United States National (Nationwide) Inpatient Sample from 2005 to 2014. All hospitalizations for patients diagnosed with primary PH and over the age of 65 years were included and then grouped based on the presence AF. The outcomes were in-hospital mortality rate, hospital length of stay, and hospitalization costs. Weighted regression analyses were performed to find the association between AF and outcomes. Of the 5,428,332 hospitalizations with PH, 2,531,075 (46.6%) had concomitant AF. The Cox proportional regression analysis showed that in patients with PE, all-cause mortality (hazard ratio 1.35, confidence interval [CI] 1.15 to 1.55) was significantly higher in patients with AF than those without AF. In addition, PH hospitalizations with AF had a longer hospital length of stay (β coefficient 1.74, 95% CI 1.58 to 1.83) and higher hospitalization cost (β coefficient 1.33, 95% CI 1.12 to 1.42). In patients aged over 65 years admitted for PH, the presence of AF was very frequent and worsened the prognosis. In conclusion, to improve patient outcomes and decrease hospital burden, it is important to consider AF during risk stratification for patients with PH to provide timely and prompt interventions. An interdisciplinary approach to treatment should be used to account for the burden of co-morbidities in this population.
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Affiliation(s)
- Muni Rubens
- Office of Clinical Research; Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Universidad Espiritu Santo, Guayaquil, Ecuador
| | | | - Anshul Saxena
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Center for Advanced Analytics, and
| | - Javier Jimenez
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida
| | - Shebin George
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Jiana Baker
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Juan Ruiz
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Sandra Chaparro
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida.
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 231] [Impact Index Per Article: 231.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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6
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Hou J, Lu K, Chen P, Wang P, Li J, Yang J, Liu Q, Xue Q, Tang Z, Pei H. Comprehensive viewpoints on heart rate variability at high altitude. Clin Exp Hypertens 2023; 45:2238923. [PMID: 37552638 DOI: 10.1080/10641963.2023.2238923] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/11/2023] [Accepted: 07/14/2023] [Indexed: 08/10/2023]
Abstract
OBJECTIVES Hypoxia is a physiological state characterized by reduced oxygen levels in organs and tissues. It is a common clinicopathological process and a major cause of health problems in highland areas. Heart rate variability (HRV) is a measure of the balance in autonomic innervation to the heart. It provides valuable information on the regulation of the cardiovascular system by neurohumoral factors, and changes in HRV reflect the complex interactions between multiple systems. In this review, we provide a comprehensive overview of the relationship between high-altitude hypoxia and HRV. We summarize the different mechanisms of diseases caused by hypoxia and explore the changes in HRV across various systems. Additionally, we discuss relevant pharmaceutical interventions. Overall, this review aims to provide research ideas and assistance for in-depth studies on HRV. By understanding the intricate relationship between high-altitude hypoxia and HRV, we can gain insights into the underlying mechanisms and potential therapeutic approaches to mitigate the effects of hypoxia on cardiovascular and other systems. METHODS The relevant literature was collected systematically from scientific database, including PubMed, Web of Science, China National Knowledge Infrastructure (CNKI), Baidu Scholar, as well as other literature sources, such as classic books of hypoxia. RESULTS There is a close relationship between heart rate variability and high-altitude hypoxia. Heart rate variability is an indicator that evaluates the impact of hypoxia on the cardiovascular system and other related systems. By improving the observation of HRV, we can estimate the progress of cardiovascular diseases and predict the impact on other systems related to cardiovascular health. At the same time, changes in heart rate variability can be used to observe the efficacy of preventive drugs for altitude related diseases. CONCLUSIONS HRV can be used to assess autonomic nervous function under various systemic conditions, and can be used to predict and monitor diseases caused by hypoxia at high altitude. Investigating the correlation between high altitude hypoxia and heart rate variability can help make HRV more rapid, accurate, and effective for the diagnosis of plateau-related diseases.
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Affiliation(s)
- Jun Hou
- Department of Cardiology, Chengdu Third People's Hospital, Affiliated Hospital of Southwest Jiao Tong University, Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
| | - Keji Lu
- School of Medical and Life Sciences, Chengdu University of TCM, Chengdu, China
| | - Peiwen Chen
- School of Medical and Life Sciences, Chengdu University of TCM, Chengdu, China
| | - Peng Wang
- Department of Cardiology, The General Hospital of Western Theater Command, Chengdu, China
| | - Jing Li
- Department of Cardiology, The General Hospital of Western Theater Command, Chengdu, China
| | - Jiali Yang
- Department of Cardiology, Chengdu Third People's Hospital, Affiliated Hospital of Southwest Jiao Tong University, Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
| | - Qing Liu
- Department of Medical Engineering, The 950th Hospital of PLA, Yecheng, Xinjiang, China
| | - Qiang Xue
- Department of Cardiology Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Zhaobing Tang
- Department of Rehabilitation Medicine, The General Hospital of Western Theater Command, Chengdu, China
| | - Haifeng Pei
- Department of Cardiology, The General Hospital of Western Theater Command, Chengdu, China
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Savale L, Kularatne M, Roche A, Pichon J, Baron A, Boucly A, Sitbon O, Humbert M. Management of Acutely Decompensated Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:762-770. [PMID: 37369216 DOI: 10.1055/s-0043-1770119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Pulmonary arterial hypertension is a severe life-threatening condition associated with increased pulmonary vascular resistance and resulting right heart dysfunction. Admission to intensive care unit with acutely decompensated right heart failure is a significant negative prognostic event with a high risk of multisystem organ dysfunction and death. Presentations are heterogenous and may combine signs of both diastolic and systolic dysfunction complicating management. Renal dysfunction is often present, but other organ systems can be involved resulting in findings such as acute hepatic dysfunction or bowel wall congestion and ischemia. The goals of therapy are to rapidly reverse ventriculo-arterial decoupling and reduce right ventricular afterload to prevent progression to refractory or irreversible right heart failure. Triggering events must be investigated for and addressed urgently if identified. Volume status management is critical and both noninvasive and invasive testing can aid in prognostication and guide management, including the use of inotropes and vasopressors. In cases of refractory right heart dysfunction, consideration of urgent lung transplantation and mechanical circulatory support is necessary. These patients should be managed at expert centers in an intensive care setting with a multidisciplinary team of practitioners experienced in the management of right heart dysfunction given the high short- and long-term mortality resulting from acute decompensated right heart failure.
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Affiliation(s)
- Laurent Savale
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Mithum Kularatne
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Calgary, Canada
| | - Anne Roche
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Jérémie Pichon
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Audrey Baron
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Athenaïs Boucly
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Olivier Sitbon
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Marc Humbert
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
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Seitler S, Dimopoulos K, Ernst S, Price LC. Medical Emergencies in Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:777-796. [PMID: 37595615 DOI: 10.1055/s-0043-1770120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
The management of acute medical emergencies in patients with pulmonary hypertension (PH) can be challenging. Patients with preexisting PH can rapidly deteriorate due to right ventricular decompensation when faced with acute physiological challenges that would usually be considered low-risk scenarios. This review considers the assessment and management of acute medical emergencies in patients with PH, encompassing both pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH), acknowledging these comprise the more severe groups of PH. Management protocols are described in a systems-based approach. Respiratory emergencies include pulmonary embolism, airways disease, and pneumonia; cardiac emergencies including arrhythmia and chest pain with acute myocardial infarction are discussed, alongside PH-specific emergencies such as pulmonary artery dissection and extrinsic coronary artery compression by a dilated proximal pulmonary artery. Other emergencies including sepsis, severe gastroenteritis with dehydration, syncope, and liver failure are also considered. We propose management recommendations for medical emergencies based on available evidence, international guidelines, and expert consensus. We aim to provide advice to the specialist alongside the generalist, and emergency doctors, nurses, and acute physicians in nonspecialist centers. A multidisciplinary team approach is essential in the management of patients with PH, and communication with local and specialist PH centers is paramount. Close hemodynamic monitoring during medical emergencies in patients with preexisting PH is vital, with early referral to critical care recommended given the frequent deterioration and high mortality in this setting.
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Affiliation(s)
- Samuel Seitler
- National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Konstantinos Dimopoulos
- National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Adult Congenital Heart Disease Service, Royal Brompton Hospital, London, United Kingdom
| | - Sabine Ernst
- Adult Congenital Heart Disease Service, Royal Brompton Hospital, London, United Kingdom
| | - Laura C Price
- National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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10
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Kumari J, Advani M, Purohit G. Prevalence of pulmonary hypertension in chronic simple silicosis patients and its correlation with smoking history, occupation type, age and duration of silica exposure. Monaldi Arch Chest Dis 2023. [PMID: 38037897 DOI: 10.4081/monaldi.2023.2719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/15/2023] [Indexed: 12/02/2023] Open
Abstract
Silicosis is a preventable occupational health hazard with potential for permanent physical disability and increased socio-economic burden. Pulmonary hypertension (PH) secondary to chronic respiratory diseases signifies poorer prognosis and transthoracic echocardiography (TTE) has proven its usefulness as a screening tool for PH diagnosis. The objectives were to determine PH prevalence in chronic simple silicosis patients through TTE screening and correlate PH prevalence with smoking status, occupation type, age and duration of silica exposure (DSE). We enrolled 104 patients in the study based on occupational exposure to silica dust and radiologic confirmation of chronic simple silicosis. The study sample was divided into significant smokers (SS group) and insignificant smokers (InS group) on the basis of ≥10 pack years smoking history, and into drillers and dressers based on occupation type. TTE examination was performed to measure resting mean pulmonary artery pressure (mPAP) and the patients were classified into: no PH (mPAP≤20 mm Hg), borderline PH (mPAP>20 and <25 mmHg), and PH (mPAP≥25). PH prevalence was 25% in study subjects (26/104); 29.6% (16/54) among SS group versus 20% (10/50) among InS group (.52) ; and 34.2% (14/41) among drillers versus 19.1% (12/63) among dressers (p=.024). Mean age and mean duration of silica exposure among SS and InS groups were comparatively similar, while they had lower values among dressers against dressers with no statistical significance. Logistic regression analysis established a significant association of PH prevalence with higher age in the study sample, SS group and drillers group, while a significant association of PH prevalence with longer DSE was only seen in the study sample. PH prevalence was significantly associated (p=.007) with SS-driller group on comparing TTE findings with combined smoking and occupation type based groups. This study has shown PH prevalence in chronic simple silicosis patients at alarming levels, having associations with driller occupation, older age and longer DSE with varying results among groups and complex interplay with smoking exposure, suggesting the need for large sample-based molecular and genetic studies. Including TTE in the initial work-up of silicosis patients will promote timely intervention and reduce morbidity and mortality with a high benefit-cost ratio.
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Affiliation(s)
- Jyoti Kumari
- Department of Respiratory Medicine, Pacific Medical College and Hospital, Udaipur, Rajasthan.
| | - Manish Advani
- Department of Respiratory Medicine, Pacific Medical College and Hospital, Udaipur, Rajasthan.
| | - Gopal Purohit
- Department of Respiratory Medicine, Dr. Sampurnanand Medical College, Jodhpur, Rajasthan.
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11
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Ferrero P, Krishnathasan K, Constantine A, Chessa M, Dimopoulos K. Pulmonary arterial hypertension in congenital heart disease. Heart 2023:heartjnl-2023-322890. [PMID: 37963728 DOI: 10.1136/heartjnl-2023-322890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Affiliation(s)
- Paolo Ferrero
- Adult Congenital Heart Disease Unit, Pediatric and Adult Congenital Heart Centre, IRCCS-Policlinico San Donato, Milan, Italy
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart, Rome, Italy
| | - Kaushiga Krishnathasan
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Andrew Constantine
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Massimo Chessa
- Adult Congenital Heart Disease Unit, Pediatric and Adult Congenital Heart Centre, IRCCS-Policlinico San Donato, Milan, Italy
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart, Rome, Italy
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
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12
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Esparham A, Shoar S, Mehri A, Modukuru VR. Bariatric Surgery and Cardiovascular Disease Risk in Patients with Pulmonary Hypertension: A Propensity Score Matched Analysis of US National Inpatient Sample. Obes Surg 2023; 33:3230-3236. [PMID: 37639208 DOI: 10.1007/s11695-023-06799-6] [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: 06/16/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 08/29/2023]
Abstract
PURPOSE Previous research has suggested the ameliorating effect of bariatric surgery (BaS) on patients with pulmonary hypertension (PH), but there is a lack of data on the effect of bariatric surgery on the odds of cardiovascular diseases in PH patients. The current study aims to evaluate the association of BaS and coronary artery diseases (CAD), heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), cardiac valve diseases, cardiac rhythm disorders, acute pulmonary embolism, and in-hospital mortality in patients with PH. METHODS The national inpatient sample (NIS) data from 2016 to 2019 were analyzed by using ICD-10 codes. A propensity score matching in a 3:1 ratio was performed to match the BaS and non-BaS groups. RESULTS A total of 3605 patients with a history of BaS and 501419 patients without a history of BaS were included. After propensity matching, BaS was independently associated with a lower CAD hospital admission and a lower rate of in-hospital mortality. On the contrary, BaS was associated with a higher prevalence of atrial fibrillation (AF) and acute pulmonary embolism in patients with PH. HFpEF, HFrEF, other cardiac rhythm disorders, complete heart block, cardiac valve diseases, and ischemic stroke were not significantly different between the two groups in patients with PH. CONCLUSION BaS is independently associated with a reduced rate of in-hospital mortality and CAD hospital admission in patients with PH. However, the risk of atrial fibrillation and acute pulmonary embolism was higher in these patients.
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Affiliation(s)
- Ali Esparham
- Student Research Committee, College of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Saeed Shoar
- Department of Clinical Research, ScientificWriting Corp, Houston, TX, USA
| | - Ali Mehri
- Endoscopic and Minimally Invasive Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Venkat R Modukuru
- Bariatric and Metabolic Surgery Program, Newark Beth Israel Medical Center, RWJ Barnabas Health, Rutgers NJ Medical School, Newark, NJ, USA
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13
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Orji R, Markson F, Ilelaboye A, Okoronkwo E, Shaka H, Ayinde H, Teme T. Pulmonary Hypertension Is Associated with Worse Outcomes in Patients Hospitalized for Sick Sinus Syndrome. J Innov Card Rhythm Manag 2023; 14:5622-5628. [PMID: 37927394 PMCID: PMC10621623 DOI: 10.19102/icrm.2023.14105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 05/31/2023] [Indexed: 11/07/2023] Open
Abstract
Sick sinus syndrome (SSS) is a condition of the sinoatrial node that arises from a constellation of aberrant rhythms, resulting in reduced pacemaker activity and impulse transmission. According to the World Health Organization, pulmonary hypertension (PH) is defined by a mean pulmonary arterial pressure of >25 mmHg at rest, measured during right heart catheterization. It can result in right atrial remodeling, which may predispose the patient to sinus node dysfunction. This study sought to estimate the impact of PH on clinical outcomes of hospitalizations with SSS. The U.S. National Inpatient Sample database from 2016-2019 was searched for hospitalized adult patients with SSS as a principal diagnosis with and without PH as a secondary diagnosis using the International Classification of Diseases, Tenth Revision, codes. The primary outcome was inpatient mortality. The secondary outcomes were acute kidney injury (AKI), cardiogenic shock (CS), cardiac arrest, rates of pacemaker insertion, total hospital charges (THCs), and length of stay (LOS). Multivariate regression analysis was used to adjust for confounders. A total of 181,230 patients were admitted for SSS; 8.3% (14,990) had underlying PH. Compared to patients without PH, patients admitted with coexisting PH had a statistically significant increase in mortality (95% confidence interval, 1.21-2.32; P = .002), AKI (P < .001), CS (P = .004), THC (P = .037), and LOS (P < .001). In conclusion, patients admitted primarily for SSS with coexisting PH had a statistically significant increase in mortality, AKI, CS, THC, and LOS. Additional studies geared at identifying and addressing the underlying etiologies for PH in this population may be beneficial in the management of this patient group.
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Affiliation(s)
- Richard Orji
- Department of Medicine, Rosalind Franklin University of Medicine & Science, North Chicago, IL, USA
- Department of Medicine, Northwestern Medicine McHenry Hospital, McHenry, IL, USA
- Department of Management, University of Massachusetts Amherst, Amherst, MA, USA
| | - Favour Markson
- Department of Medicine, Lincoln Medical Center, New York, NY, USA
| | - Ayodeji Ilelaboye
- Department of Medicine, Lautech Teaching Hospital, Ogbomoso, Oyo, Nigeria
| | - Emeka Okoronkwo
- Department of Medicine, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Hafeez Shaka
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Hakeem Ayinde
- Division of Cardiology, Novant Health Heart & Vascular Institute Charlotte, Charlotte, NC, USA
| | - Tonye Teme
- Division of Cardiology, Northwestern Medicine, McHenry Hospital, McHenry, IL, USA
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14
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Teixeira-Fonseca JL, Joviano-Santos JV, Machado FS, da Silva PL, Conceição MRL, Roman-Campos D. Isolated Left Atrium Morphofunctional Study of an Experimental Pulmonary Hypertension Model in Rats. Arq Bras Cardiol 2023; 120:e20230188. [PMID: 37878960 PMCID: PMC10548886 DOI: 10.36660/abc.20230188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/27/2023] [Accepted: 08/16/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The high incidence of atrial arrhythmias in pulmonary hypertension (PH) might be associated with poor prognosis, and the left atrium (LA) may play a role in this. An important finding in PH studies is that LA remodeling is underestimated. OBJECTIVE This study investigated LA morphology and mechanical function, as well as the susceptibility to develop arrhythmias in a monocrotaline-induced PH (MCT-PH) model. METHODS Wistar rats aged 4 weeks received 50 mg/kg of MCT. Electrocardiography and histology analysis were performed to evaluate the establishment of the MCT-PH model. The tissue was mounted in an isolated organ bath to characterize the LA mechanical function. RESULTS Compared with the control group (CTRL), the MCT-PH model presented LA hypertrophy and changes in cardiac electrical activity, as evidenced by increased P wave duration, PR and QT interval in MCT-PH rats. In LA isolated from MCT-PH rats, no alteration in inotropism was observed; however, the time to peak contraction was delayed in the experimental MCT-PH group. Finally, there was no difference in arrhythmia susceptibility of LA from MCT-PH animals after the burst pacing protocol. CONCLUSION The morphofunctional remodeling of the LA did not lead to increased susceptibility to ex vivo arrhythmia after application of the burst pacing protocol.
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Affiliation(s)
| | - Julliane Vasconcelos Joviano-Santos
- Faculdade de Ciências Médicas de Minas GeraisBelo HorizonteMGBrasil Faculdade de Ciências Médicas de Minas Gerais , Belo Horizonte , MG – Brasil
| | - Fabiana Silva Machado
- Universidade Federal de São PauloSão PauloSPBrasil Universidade Federal de São Paulo , São Paulo , SP – Brasil
| | - Polyana Leal da Silva
- Universidade Federal de São PauloSão PauloSPBrasil Universidade Federal de São Paulo , São Paulo , SP – Brasil
| | | | - Danilo Roman-Campos
- Universidade Federal de São PauloSão PauloSPBrasil Universidade Federal de São Paulo , São Paulo , SP – Brasil
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15
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Rajapreyar I, Soliman O, Brailovsky Y, Tedford RJ, Gibson G, Mohacsi P, Hajduczok AG, Tchantchaleishvili V, Wieselthaler G, Rame JE, Caliskan K. Late Right Heart Failure After Left Ventricular Assist Device Implantation: Contemporary Insights and Future Perspectives. JACC. HEART FAILURE 2023; 11:865-878. [PMID: 37269258 DOI: 10.1016/j.jchf.2023.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 03/21/2023] [Accepted: 04/19/2023] [Indexed: 06/05/2023]
Abstract
Late right heart failure (RHF) is increasingly recognized in patients with long-term left ventricular assist device (LVAD) support and is associated with decreased survival and increased incidence of adverse events such as gastrointestinal bleeding and stroke. Progression of right ventricular (RV) dysfunction to clinical syndrome of late RHF in patients supported with LVAD is dependent on the severity of pre-existing RV dysfunction, persistent or worsening left- or right-sided valvular heart disease, pulmonary hypertension, inadequate or excessive left ventricular unloading, and/or progression of the underlying cardiac disease. RHF likely represents a continuum of risk with early presentation and progression to late RHF. However, de novo RHF develops in a subset of patients leading to increased diuretic requirement, arrhythmias, renal and hepatic dysfunction, and heart failure hospitalizations. The distinction between isolated late RHF and RHF due to left-sided contributions is lacking in registry studies and should be the focus of future registry data collection. Potential management strategies include optimization of RV preload and afterload, neurohormonal blockade, LVAD speed optimization, and treatment of concomitant valvular disease. In this review, the authors discuss definition, pathophysiology, prevention, and management of late RHF.
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Affiliation(s)
- Indranee Rajapreyar
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Osama Soliman
- Discipline of Cardiology, University Hospital Galway, School of Medicine, University of Galway, Ireland
| | - Yevgeniy Brailovsky
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gregory Gibson
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Paul Mohacsi
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Alexander G Hajduczok
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Vakhtang Tchantchaleishvili
- Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Georg Wieselthaler
- Division of Adult Cardiothoracic Surgery, University of California, San Francisco, California, USA
| | - J Eduardo Rame
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kadir Caliskan
- Thoraxcenter, Department of Cardiology, Erasmus Medical Center University Medical Center, Rotterdam, the Netherlands
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16
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Vijan A, Daha IC, Delcea C, Dan GA. The complex interplay between right ventricular dysfunction and atrial fibrillation - a narrative review. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2023; 61:77-83. [PMID: 36762789 DOI: 10.2478/rjim-2023-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Indexed: 05/10/2023]
Abstract
Atrial fibrillation (AF) is one of the most common sustained arrhythmias in clinical practice, associated with multiple comorbidities and complication. The potential predictors of AF onset and perpetuation or specific drivers of complications need future investigation. Right ventricular (RV) dysfunction plays an important role in the development of new-onset AF warranting in-depth analysis in relation to AF. RV may play a significant role in a better characterization of the cardiac substrate of AF patients. The relation between RV dysfunction and AF is bidirectional as AF may be one of the causes of RV dysfunction and their coexistence worsens the overall patient prognosis. Our aim is to present in a narrative review the most relevant data regarding the complex relationship between AF and RV dysfunction.
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Affiliation(s)
- Ancuta Vijan
- 1Carol Davila University of Medicine and Pharmacy, Bucharest
- 2Colentina Clinical Hospital, Bucharest, Romania
| | - Ioana Cristina Daha
- 1Carol Davila University of Medicine and Pharmacy, Bucharest
- 2Colentina Clinical Hospital, Bucharest, Romania
| | - Caterina Delcea
- 1Carol Davila University of Medicine and Pharmacy, Bucharest
- 2Colentina Clinical Hospital, Bucharest, Romania
| | - Gheorghe-Andrei Dan
- 1Carol Davila University of Medicine and Pharmacy, Bucharest
- 2Colentina Clinical Hospital, Bucharest, Romania
- 3Joint senior author
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17
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Havranek S, Fingrova Z, Skala T, Reichenbach A, Dusik M, Jansa P, Ambroz D, Dytrych V, Klimes D, Hutyra M, Kautzner J, Linhart A, Wichterle D. Catheter ablation of atrial fibrillation and atrial tachycardia in patients with pulmonary hypertension: a randomized study. Europace 2023:7161651. [PMID: 37178136 DOI: 10.1093/europace/euad131] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/14/2023] [Indexed: 05/15/2023] Open
Abstract
AIMS Atrial fibrillation (AF), typical atrial flutter (AFL), and other atrial tachycardias (ATs) are common in patients with pulmonary hypertension. Frequently, several supraventricular arrhythmias are successively observed in individual patients. We investigated the hypothesis of whether more extensive radiofrequency catheter ablation of the bi-atrial arrhythmogenic substrate instead of clinical arrhythmia ablation alone results in superior clinical outcomes in patients with pulmonary arterial hypertension (PH) and supraventricular arrhythmias. METHODS AND RESULTS Patients with combined post- and pre-capillary or isolated pre-capillary PH and supraventricular arrhythmia indicated to catheter ablation were enrolled in three centres and randomized 1:1 into two parallel treatment arms. Patients underwent either clinical arrhythmia ablation only (Limited ablation group) or clinical arrhythmia plus substrate-based ablation (Extended ablation group). The primary endpoint was arrhythmia recurrence >30 s without antiarrhythmic drugs after the 3-month blanking period. A total of 77 patients (mean age 67 ± 10 years; 41 males) were enrolled. The presumable clinical arrhythmia was AF in 38 and AT in 36 patients, including typical AFL in 23 patients. During the median follow-up period of 13 (interquartile range: 12; 19) months, the primary endpoint occurred in 15 patients (42%) vs. 17 patients (45%) in the Extended vs. Limited ablation group (hazard ratio: 0.97, 95% confidence interval: 0.49-2.0). There was no excess of procedural complications and clinical follow-up events including an all-cause death in the Extended ablation group. CONCLUSION Extensive ablation, compared with a limited approach, was not beneficial in terms of arrhythmia recurrence in patients with AF/AT and PH. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov; NCT04053361.
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Affiliation(s)
- Stepan Havranek
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Zdenka Fingrova
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Tomas Skala
- First Department of Internal Medicine-Cardiology, Olomouc University Hospital, Olomouc, Czech Republic
| | - Adrian Reichenbach
- Cardiology Department, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Milan Dusik
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Pavel Jansa
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - David Ambroz
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Vladimir Dytrych
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Dalibor Klimes
- First Department of Internal Medicine-Cardiology, Olomouc University Hospital, Olomouc, Czech Republic
| | - Martin Hutyra
- First Department of Internal Medicine-Cardiology, Olomouc University Hospital, Olomouc, Czech Republic
| | - Josef Kautzner
- Cardiology Department, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ales Linhart
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Dan Wichterle
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
- Cardiology Department, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
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18
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Sammut MA, Condliffe R, Elliot C, Hameed A, Lewis R, Kiely DG, Kyriacou A, Middleton JT, Raithatha A, Rothman A, Thompson AAR, Turner R, Charalampopoulos A. Atrial flutter and fibrillation in patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension in the ASPIRE registry: Comparison of rate versus rhythm control approaches. Int J Cardiol 2023; 371:363-370. [PMID: 36130620 DOI: 10.1016/j.ijcard.2022.09.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/06/2022] [Accepted: 09/13/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The development of atrial flutter and fibrillation (AFL/AF) in patients with pre-capillary pulmonary hypertension has been associated with an increased risk of morbidity and mortality. Rate and rhythm control strategies have not been directly compared. METHODS Eighty-four patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) with new-onset AFL/AF were identified in the ASPIRE registry. First, baseline characteristics and rates of sinus rhythm (SR) restoration of 3 arrhythmia management strategies (rate control, medical rhythm control and DC cardioversion, DCCV) in an early (2009-13) and later (2014-19) cohort were compared. Longer-term outcomes in patients who achieved SR versus those who did not were then explored. RESULTS Sixty (71%) patients had AFL and 24 (29%) AF. Eighteen (22%) patients underwent rate control, 22 (26%) medical rhythm control and 44 (52%) DCCV. SR was restored in 33% treated by rate control, 59% medical rhythm control and 95% DCCV (p < 0.001). Restoration of SR was associated with greater improvement in functional class (FC) and Incremental Shuttle Walk Distance (p both <0.05). It also independently predicted superior survival (3-year survival 62% vs 23% in those remaining in AFL/AF, p < 0.0001). In addition, FC III/IV independently predicted higher mortality (HR 2.86, p = 0.007). Right atrial area independently predicted AFL/AF recurrence (OR 1.08, p = 0.01). DCCV was generally well tolerated with no immediate major complications. CONCLUSIONS Restoration of SR is associated with superior functional improvement and survival in PAH/CTEPH compared with rate control. DCCV is generally safe and is more effective than medical therapy at achieving SR.
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Affiliation(s)
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Charlie Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Abdul Hameed
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Robert Lewis
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Andreas Kyriacou
- Department of Cardiology, Northern General Hospital, Sheffield, UK
| | - Jennifer T Middleton
- Department of Cardiology, Northern General Hospital, Sheffield, UK; Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Ajay Raithatha
- Department of Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Alex Rothman
- Department of Cardiology, Northern General Hospital, Sheffield, UK; Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - A A Roger Thompson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Richard Turner
- Department of Respiratory Medicine, Imperial College Healthcare Trust, London, UK
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.
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19
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Hendriks PM, Kauling RM, Geenen LW, Eindhoven JA, Roos-Hesselink JW, Boomars KA, van den Bosch AE. Role of the electrocardiogram in the risk stratification of pulmonary hypertension. Heart 2023; 109:208-215. [PMID: 36171071 DOI: 10.1136/heartjnl-2022-321475] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/12/2022] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION The prognosis of pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) remains dismal. Better risk prediction is needed. This study investigated the prognostic value of ECG characteristics. METHODS In this single-centre prospective study, consecutive treatment-naïve patients with PAH or CTEPH were included at time of diagnosis. From the 12-lead ECG, obtained at baseline, the following parameters were collected: heart rate (HR), rhythm, QRS axis, conduction times, P-top amplitudes in II, R-top and S-wave amplitudes in V1 and V5 and repolarisation disorders. Associations between the ECG and transplant-free survival was assessed by Kaplan-Meier curves and Cox-proportional hazard regressions. RESULTS In total, 140 patients were included (median age: 60.7 years, 63.6% female). The ECG was abnormal in 86.2%: sinus rhythm was not present in 9.3%, right QRS axis was observed in 47.8%, mean QRS duration was 101±17 ms. Only 42.5% of the patients had normal repolarisation, 34.5% had right ventricular strain and 14.4% non-specific repolarisation disorders. Over a median follow-up time of 3.49 (IQR: 1.37-6.42) years, 45 patients (32.5%) died or underwent lung transplantation. Transplant-free survival was worse in patients presenting with an abnormal ECG (64.0% vs 86.0%; p=0.037). The following ECG characteristics were associated with all-cause mortality or lung transplantation: heart rate (HR 1.02, 95% CI: 1.00 to 1.05), QRS duration >120 ms (HR 2.61, 95% CI: 1.01 to 6.71) and S-wave amplitude in V5 (HR 1.10, 95% CI: 1.04 to 1.17). CONCLUSION Only 13.8% of patients with PAH and CTEPH presented with a normal ECG, which is associated with favourable outcome. The ECG provides additional prognostic value to current clinical parameters and should be considered in risk prediction.
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Affiliation(s)
- Paul M Hendriks
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Respiratory Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Robert M Kauling
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Laurie W Geenen
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jannet A Eindhoven
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Karin A Boomars
- Department of Respiratory Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
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20
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Bousseau S, Sobrano Fais R, Gu S, Frump A, Lahm T. Pathophysiology and new advances in pulmonary hypertension. BMJ MEDICINE 2023; 2:e000137. [PMID: 37051026 PMCID: PMC10083754 DOI: 10.1136/bmjmed-2022-000137] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/02/2023] [Indexed: 04/14/2023]
Abstract
Pulmonary hypertension is a progressive and often fatal cardiopulmonary condition characterised by increased pulmonary arterial pressure, structural changes in the pulmonary circulation, and the formation of vaso-occlusive lesions. These changes lead to increased right ventricular afterload, which often progresses to maladaptive right ventricular remodelling and eventually death. Pulmonary arterial hypertension represents one of the most severe and best studied types of pulmonary hypertension and is consistently targeted by drug treatments. The underlying molecular pathogenesis of pulmonary hypertension is a complex and multifactorial process, but can be characterised by several hallmarks: inflammation, impaired angiogenesis, metabolic alterations, genetic or epigenetic abnormalities, influence of sex and sex hormones, and abnormalities in the right ventricle. Current treatments for pulmonary arterial hypertension and some other types of pulmonary hypertension target pathways involved in the control of pulmonary vascular tone and proliferation; however, these treatments have limited efficacy on patient outcomes. This review describes key features of pulmonary hypertension, discusses current and emerging therapeutic interventions, and points to future directions for research and patient care. Because most progress in the specialty has been made in pulmonary arterial hypertension, this review focuses on this type of pulmonary hypertension. The review highlights key pathophysiological concepts and emerging therapeutic directions, targeting inflammation, cellular metabolism, genetics and epigenetics, sex hormone signalling, bone morphogenetic protein signalling, and inhibition of tyrosine kinase receptors.
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Affiliation(s)
- Simon Bousseau
- Division of Pulmonary, Sleep, and Critical Care Medicine, National Jewish Health, Denver, CO, USA
| | - Rafael Sobrano Fais
- Division of Pulmonary, Sleep, and Critical Care Medicine, National Jewish Health, Denver, CO, USA
| | - Sue Gu
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Cardiovascular Pulmonary Research Lab, University of Colorado School of Medicine, Aurora, CO, USA
| | - Andrea Frump
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tim Lahm
- Division of Pulmonary, Sleep, and Critical Care Medicine, National Jewish Health, Denver, CO, USA
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Regional Veteran Affairs Medical Center, Aurora, CO, USA
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21
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Bandorski D, Heibel S, Höltgen R, Bogossian H, Ghofrani HA, Zarse M, Gall H. Incidence and prognostic significance of malignant arrhythmias during (repetitive) Holter electrocardiograms in patients with pulmonary hypertension. Front Cardiovasc Med 2023; 10:1084051. [PMID: 37139131 PMCID: PMC10150006 DOI: 10.3389/fcvm.2023.1084051] [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: 10/29/2022] [Accepted: 03/20/2023] [Indexed: 05/05/2023] Open
Abstract
Background In patients with pulmonary hypertension (PH), increased pulmonary vascular resistance (PVR) may lead to increased right ventricular afterload and cardiac remodelling, potentially providing the substrate for ventricular arrhythmias. Studies dealing with long term monitoring of patients with PH are rare. The present study evaluated the incidence and the types of arrhythmias retrospectively recorded by Holter ECG in patients with newly detected PH during a long-term Holter ECG follow-up. Moreover, their impact on patient survival was evaluated. Patients and methods Medical records were screened for demographic data, aetiology of PH, incidence of coronary heart disease, level of brain natriuretic peptide (BNP), results from Holter ECG monitoring, 6-minute walk test distance, echocardiographic data and hemodynamic data derived from right heart catheterization. Two subgroups were analyzed: 1. patients (n = 65) with PH (group 1 + 4) and derivation of at least 1 Holter ECG within 12 months from initial detection of PH and 2. patients (all PH etiologies, n = 59) with 3 follow-up Holter ECGs. The frequency and complexity of premature ventricular contractions (PVC) was classified into "lower" and "higher" (=non sustained ventricular tachycardia, nsVT) burden. Results Holter ECG revealed sinus rhythm (SR) in most of the patients (n = 60). Incidence of atrial fibrillation (AFib) was low (n = 4). Patients with premature atrial contractions (PAC) tend to have a shorter period of survival (p = 0.098), PVC were not correlated with significant survival differences. During follow-up PAC and PVC were common in all PH groups. Holter ECG revealed non sustained ventricular tachycardia in 19/59 patients [(32.2%); n = 6 during first Holter-ECG, n = 13 during second/third Holter-ECG]. In all patients suffering from nsVT during follow-up previous Holter ECG revealed multiform/repetitive PVC. PVC burden was not linked to differences in systolic pulmonary arterial pressure, right atrial pressure, brain natriuretic peptide and results of six-minute walk test. Conclusion Patients with PAC tend to have a shortened survival. None of the evaluated parameters (BNP, TAPSE, sPAP) was correlated with the development of arrhythmias. Patients with multiform/repetitive PVC seem to be at risk for ventricular arrhythmias.
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Affiliation(s)
- Dirk Bandorski
- Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Correspondence: Dirk Bandorski
| | - Sebastian Heibel
- Medical Clinic III, Sana Klinikum Offenbach, Offenbach am Main, Germany
| | - Reinhard Höltgen
- Klinikum Westmünsterland, St. Agnes-Hospital Bocholt-Rhede, Bocholt, Germany
| | | | - Hossein Ardeschir Ghofrani
- The German Center for Lung Research (DZL), University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Markus Zarse
- Cardiology Department, School of Medicine, Witten/Herdecke University, Witten, Germany
| | - Henning Gall
- The German Center for Lung Research (DZL), University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
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22
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Dusik M, Fingrova Z, Marek J, Dytrych V, Jansa P, Havranek S. The impact of atrial fibrillation and atrial tachycardias on the hemodynamic status of patients with pulmonary hypertension. Physiol Res 2022. [DOI: 10.33549/physiolres.934941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The impact of atrial fibrillation and atrial tachycardias (AF/AT), and their optimal treatment strategy in PH patients is still being discussed. The goal of this study was to evaluate the effect of AF/AT termination on the hemodynamic parameters in PH patients. We compared patients with pre-capillary pulmonary hypertension (PH group), left ventricular heart failure (LV-HF group), and a Control group. A repeated right heart catheterization was performed during the catheter ablation (CA) procedure. The first measurement was done in arrhythmia, the second after the sinus rhythm (SR) was restored. High frequency atrial stimulation was used to simulate AT in patients without arrhythmia presence at the time of the CA. The variation of pressure parameters in PH patients did not differ significantly from the Controls. There was a significant increase in the right ventricle pressure after the SR restoration in the LV-HF group compared to the Controls and PH group (+4 vs. -2 vs. -3 mmHg, p < 0.05). The cardiac index (CI) variation was not significant when compared between the study groups. An increase of the CI after the SR restoration was found in those patients with AF (+0.31 l/min/m² [IQR 0.18; 0.58]) in contrast to those patients with organized AT/high frequency atrial stimulation (-0.09 l/min/m², [IQR - 0.45; 0.19]). This difference was statistically significant (p < 0.05). The acute hemodynamic response to arrhythmia termination was not significantly different in the PH patients when compared to the Controls. In contrast to AT/high frequency stimulation, the restoration of SR in AF patients leads to an increased CI, irrespective of the presence or absence of PH.
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Affiliation(s)
| | | | | | | | | | - S Havranek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, 1st Faculty of Medicine, Charles University in Prague, Czech Republic.
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23
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Zhang X, Huangfu Z. Management of pregnant patients with pulmonary arterial hypertension. Front Cardiovasc Med 2022; 9:1029057. [PMID: 36440029 PMCID: PMC9684470 DOI: 10.3389/fcvm.2022.1029057] [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: 08/26/2022] [Accepted: 10/27/2022] [Indexed: 09/19/2023] Open
Abstract
Pregnant individuals with pulmonary arterial hypertension (PAH) have significantly high risks of maternal and perinatal mortality. Profound changes in plasma volume, cardiac output and systemic vascular resistance can all increase the strain being placed on the right ventricle, leading to heart failure and cardiovascular collapse. Given the complex network of opposing physiological changes, strict contraception and reduction of hemodynamic fluctuations during pregnancy are important methods of minimizing the risk of maternal mortality and improving the outcomes following pregnancy. In this review, we discuss the recent research progress into pre-conception management and the various therapeutic strategies for pregnant individuals with PAH.
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Affiliation(s)
- Xiao Zhang
- Department of Gynecology and Obstetrics, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Peking Union Medical College, Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhao Huangfu
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
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24
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Lu YY, Lin FJ, Chen YC, Kao YH, Higa S, Chen SA, Chen YJ. Role of Endothelin-1 in Right Atrial Arrhythmogenesis in Rabbits with Monocrotaline-Induced Pulmonary Arterial Hypertension. Int J Mol Sci 2022; 23:ijms231910993. [PMID: 36232308 PMCID: PMC9569916 DOI: 10.3390/ijms231910993] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/06/2022] [Accepted: 09/15/2022] [Indexed: 12/03/2022] Open
Abstract
Atrial arrhythmias are considered prominent phenomena in pulmonary arterial hypertension (PAH) resulting from atrial electrical and structural remodeling. Endothelin (ET)-1 levels correlate with PAH severity and are associated with atrial remodeling and arrhythmia. In this study, hemodynamic measurement, western blot analysis, and histopathology were performed in the control and monocrotaline (MCT, 60 mg/kg)-induced PAH rabbits. Conventional microelectrodes were used to simultaneously record the electrical activity in the isolated sinoatrial node (SAN) and right atrium (RA) tissue preparations before and after ET-1 (10 nM) or BQ-485 (an ET-A receptor antagonist, 100 nM) perfusion. MCT-treated rabbits showed an increased relative wall thickness in the pulmonary arterioles, mean cell width, cross-sectional area of RV myocytes, and higher right ventricular systolic pressure, which were deemed to have PAH. Compared to the control, the spontaneous beating rate of SAN–RA preparations was faster in the MCT-induced PAH group, which can be slowed down by ET-1. MCT-induced PAH rabbits had a higher incidence of sinoatrial conduction blocks, and ET-1 can induce atrial premature beats or short runs of intra-atrial reentrant tachycardia. BQ 485 administration can mitigate ET-1-induced RA arrhythmogenesis in MCT-induced PAH. The RA specimens from MCT-induced PAH rabbits had a smaller connexin 43 and larger ROCK1 and phosphorylated Akt than the control, and similar PKG and Akt to the control. In conclusion, ET-1 acts as a trigger factor to interact with the arrhythmogenic substrate to initiate and maintain atrial arrhythmias in PAH. ET-1/ET-A receptor/ROCK signaling may be a target for therapeutic interventions to treat PAH-induced atrial arrhythmias.
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Affiliation(s)
- Yen-Yu Lu
- Division of Cardiology, Sijhih Cathay General Hospital, New Taipei City 22174, Taiwan
- School of Medicine, Fu-Jen Catholic University, New Taipei City 24257, Taiwan
| | - Fong-Jhih Lin
- Department of Biomedical Engineering, National Defense Medical Center, Taipei 11490, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11042, Taiwan
| | - Yao-Chang Chen
- Department of Biomedical Engineering, National Defense Medical Center, Taipei 11490, Taiwan
| | - Yu-Hsun Kao
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11042, Taiwan
- Department of Medical Education and Research, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
| | - Satoshi Higa
- Cardiac Electrophysiology and Pacing Laboratory, Division of Cardiovascular Medicine, Makiminato Central Hospital, Okinawa 901-2131, Japan
| | - Shih-Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan
- Correspondence: (S.-A.C.); (Y.-J.C.)
| | - Yi-Jen Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11042, Taiwan
- Cardiovascular Research Center, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
- Correspondence: (S.-A.C.); (Y.-J.C.)
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25
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Andersen MØ, Diederichsen SZ, Svendsen JH, Carlsen J. Continuous cardiac monitoring in a patient with terminal pulmonary hypertension and eventual bilateral lung transplantation. BMJ Case Rep 2022; 15:15/6/e248304. [PMID: 35667702 PMCID: PMC9171191 DOI: 10.1136/bcr-2021-248304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
As pulmonary arterial hypertension (PAH) progress, arrhythmias are becoming an increasingly prominent phenomenon. Supraventricular tachycardias have been shown to have an incidence of up to 35% in pulmonary hypertension. Continuous cardiac monitoring was deployed in a patient with severe PAH 100 days before bilateral lung transplantation (BLTX). Despite being graded as WHO functional class IV, no arrhythmias were observed before BLTX. Furthermore, the case describes clinical improvement, along with a significant increase in heart rate variability (HRV) and decrease in night-time heart rate in the post-transplantation period. No arrhythmias were observed preoperatively during continuous monitoring in a 100-day period despite the patient’s intrinsically high risk for arrhythmias. Increasing HRV and lower resting heart rate were observed after BLTX. Since these parameters correlate with the clinical condition, they might be valuable in risk assessment in patients with pulmonary hypertension.
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Affiliation(s)
- Mads Ørbæk Andersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren Zöga Diederichsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jørn Carlsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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26
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Kostura M, Smalley C, Koyfman A, Long B. Right heart failure: A narrative review for emergency clinicians. Am J Emerg Med 2022; 58:106-113. [PMID: 35660367 DOI: 10.1016/j.ajem.2022.05.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/18/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Right heart failure (RHF) is a clinical syndrome with impaired right ventricular cardiac output due to a variety of etiologies including ischemia, elevated pulmonary arterial pressure, or volume overload. Emergency department (ED) patients with an acute RHF exacerbation can be diagnostically and therapeutically challenging to manage. OBJECTIVE This narrative review describes the pathophysiology of right ventricular dysfunction and pulmonary hypertension, the methods to diagnose RHF in the ED, and management strategies. DISCUSSION Right ventricular contraction normally occurs against a low pressure, highly compliant pulmonary vascular system. This physiology makes the right ventricle susceptible to acute changes in afterload, which can lead to RHF. Patients with acute RHF may present with an acute illness and have underlying chronic pulmonary hypertension due to left ventricular failure, pulmonary arterial hypertension, chronic lung conditions, thromboemboli, or idiopathic conditions. Patients can present with a variety of symptoms resulting from systemic edema and hemodynamic compromise. Evaluation with electrocardiogram, laboratory analysis, and imaging is necessary to evaluate cardiac function and end organ injury. Management focuses on treating the underlying condition, optimizing oxygenation and ventilation, treating arrhythmias, and understanding the patient's hemodynamics with bedside ultrasound. As RHF patients are preload dependent they may require fluid resuscitation or diuresis. Hypotension should be rapidly addressed with vasopressors. Cardiac contractility can be augmented with inotropes. Efforts should be made to support oxygenation while trying to avoid intubation if possible. CONCLUSIONS Emergency clinician understanding of this condition is important to diagnose and treat this life-threatening cardiopulmonary disorder.
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Affiliation(s)
- Matthew Kostura
- Department of Emergency Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Courtney Smalley
- Department of Emergency Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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27
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Stubbs H, MacLellan A, McGettrick M, Jani B, Brewis M, Church C, Johnson M. Predicting Group II pulmonary hypertension: diagnostic accuracy of the H2FPEF and OPTICS scores in Scotland. Open Heart 2022; 9:openhrt-2022-002023. [PMID: 35477699 PMCID: PMC9047890 DOI: 10.1136/openhrt-2022-002023] [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: 03/18/2022] [Accepted: 04/07/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Group II pulmonary hypertension (PH) can be challenging to distinguish from Group I PH without proceeding to right heart catheterisation (RHC). The diagnostic accuracy of the H2FPEF and OPTICS scores was investigated in Scotland. METHODS Patients were included in the study if they were referred to the Scottish Pulmonary Vascular Unit between 2016 and 2020 and subsequently diagnosed with Group II PH or Group I PH which was either idiopathic, heritable or pulmonary veno-occlusive disease. The established cut offs for the H2FPEF and for the OPTICS scores were applied retrospectively to predict the presence of Group II PH. The diagnosis from the scores were compared with the MDT consensus diagnosis following RHC. RESULTS 107 patients with Group I PH and 86 patients with Group II PH were included. Retrospective application of the OPTICS score demonstrated that pretest scoring would detect 28% of cases with Group II PH yet at the cost of misdiagnosing 4% of patients with Group I as Group II PH (specificity 0.96). The H2FPEF score had a far greater sensitivity (0.70) yet reduced specificity (0.91), leading to misdiagnosis of 9% of Group I PH cases. CONCLUSION While the specificity of these scores was high, the lack of perfect specificity limits their utility as it results in missed patients with Group I PH. As a consequence, they cannot replace RHC as the means of diagnosing the aetiology of PH in their current form. The scores may still be used to support clinical judgement or to indicate the advisability for further provocative testing at RHC.
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Affiliation(s)
- Harrison Stubbs
- Scottish Pulmonary Vascular Unit, NHS Greater Glasgow and Clyde, Glasgow, UK .,Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Alexander MacLellan
- Scottish Pulmonary Vascular Unit, NHS Greater Glasgow and Clyde, Glasgow, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Michael McGettrick
- Scottish Pulmonary Vascular Unit, NHS Greater Glasgow and Clyde, Glasgow, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Bhautesh Jani
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Melanie Brewis
- Scottish Pulmonary Vascular Unit, NHS Greater Glasgow and Clyde, Glasgow, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Colin Church
- Scottish Pulmonary Vascular Unit, NHS Greater Glasgow and Clyde, Glasgow, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Martin Johnson
- Scottish Pulmonary Vascular Unit, NHS Greater Glasgow and Clyde, Glasgow, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
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28
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Jian Y, Zhou H, Wang Y, Zhang Z, Yang G, Geng C, Tian Y, Gao W, Chen W. Echocardiography-defined pulmonary hypertension is an adverse prognostic factor for newly diagnosed multiple myeloma patients. Cancer Med 2022; 11:4182-4192. [PMID: 35466549 DOI: 10.1002/cam4.4770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/23/2022] [Accepted: 04/09/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a common but rarely recognized comorbidity of multiple myeloma (MM) patients, while its prognostic significance for MM has been rarely reported. METHODS We retrospectively analyzed the clinical characteristics and prognostic value of baseline echocardiography-defined PH in 426 newly diagnosed MM (NDMM) patients. RESULTS Echocardiograph-defined PH was found in 12.7% (54/426) of NDMM patients, associated with older age, anemia, and renal insufficiency, as well as severe diastolic dysfunction and higher BNP and NT-pro-BNP levels. Patients with PH presented with a higher prevalence of atrial fibrillation, while with a similar incidence of thrombosis compared with those without PH. Based on similar treatment regimens and autologous stem cell transplantation (ASCT) rates, patients without PH have deeper and better responses than those with PH (p = 0.002). With the remission of MM, 81.5% of PH was reversible, accompanied by improvement of right ventricular dysfunction and normalization of BNP/NT-pro-BNP levels, while could reoccur at MM relapse. Survival analysis revealed that PH was an adverse prognostic factor, associated with reduced progression-free survival (PFS) (21 vs. 50 months, p < 0.001) and overall survival (OS) (45 vs. 90 months, p = 0.014). Multivariate analysis further verified that baseline PH was an independent predictor for shorter PFS and OS. CONCLUSION In conclusion, echocardiography-defined PH is an adverse prognostic indicator for MM patients and should be routinely evaluated in MM patients at diagnosis to make a precise prognosis.
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Affiliation(s)
- Yuan Jian
- Department of Hematology, Myeloma Research Center of Beijing, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Huixing Zhou
- Department of Hematology, Myeloma Research Center of Beijing, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yidan Wang
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zhiyao Zhang
- Department of Hematology, Myeloma Research Center of Beijing, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Guangzhong Yang
- Department of Hematology, Myeloma Research Center of Beijing, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Chuanying Geng
- Department of Hematology, Myeloma Research Center of Beijing, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Ying Tian
- Department of Hematology, Myeloma Research Center of Beijing, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Wen Gao
- Department of Hematology, Myeloma Research Center of Beijing, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Wenming Chen
- Department of Hematology, Myeloma Research Center of Beijing, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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29
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Xue L, Yang YC, Zhao Q, Zhao ZH, Zeng QX, Yang T, Luo Q, Liu BY, Ma XP, Liu ZH, Xiong CM. The spectrum and prevalence of arrhythmia in different clinical pulmonary hypertension groups in Chinese population. Clin Cardiol 2022; 45:495-502. [PMID: 35253244 DOI: 10.1002/clc.23803] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/17/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Arrhythmia is not uncommon among pulmonary hypertension (PH) population, and may be associated with disease severity. HYPOTHESIS To investigate different spectrums and prevalence of arrhythmias in different clinical PH groups in Chinese population. METHODS Patients diagnosed with PH between April 15, 2019, and August 2, 2021, were enrolled prospectively. The prevalence of different types of arrhythmias in PH patients were calculated. Logistic regression analyses were conducted to determine independent predictors for arrhythmia. RESULTS One thousand patients were enrolled. The prevalence of any arrhythmia, sinus node dysfunction, sinus tachycardia, atrial fibrillation, atrial flutter, other types of atrial tachycardia, atrioventricular block, and ventricular tachycardia is 44.4%, 12.2%, 15.2%, 8.1%, 4.1%, 10.2%, 7.1%, and 2.5%. Logistic regression analyses revealed that older age and larger right ventricle (odds ratio: 1.111 and 1.095, p < .05) were independently related with higher probability of supraventricular arrhythmia; Complicating with coronary artery disease, larger right ventricle, and increased left ventricular end-diastolic diameter (odds ratio: 19.540, 1.106, and 1.085, p < .05) were independently correlated with sinus node dysfunction/atrioventricular block in patients with pulmonary arterial hypertension. CONCLUSIONS Nearly half of PH patients experienced at least one type of arrhythmia. The most common seen arrhythmias were supraventricular arrhythmia, sinus tachycardia, and sinus node dysfunction. Older age and larger right ventricle were independently related with higher probability of supraventricular arrhythmia; Complicating with coronary artery disease, larger right ventricle and increased left ventricular end-diastolic diameter were independently correlated with higher probability of sinus node dysfunction/atrioventricular block in patients with pulmonary arterial hypertension.
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Affiliation(s)
- Lin Xue
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi-Cheng Yang
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qing Zhao
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Hui Zhao
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qi-Xian Zeng
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Yang
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qin Luo
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bing-Yang Liu
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiu-Ping Ma
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Hong Liu
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chang-Ming Xiong
- Department of Cardiology, Center for Diagnosis and Management of Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Karadavut S, Cetin M. A Novel Factor in Determining the Risk of Ischemic Cerebrovascular Events in Patients with Atrial Fibrillation: Pulmonary Hypertension. J Stroke Cerebrovasc Dis 2022; 31:106387. [PMID: 35182946 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106387] [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: 11/22/2021] [Revised: 01/05/2022] [Accepted: 01/31/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Pulmonary hypertension (PH) is closely related to clinical decompensation and poor clinical outcomes in atrial fibrillation (AF) patients. However, the association between PH and ischemic cerebrovascular events (ICE) in AF patients has not been investigated. The authors purposed to examine this relationship. MATERIALS AND METHODS The researchers conducted an observational study on 371 AF patients between January and November 2021. In line with the European Society of Cardiology guideline recommendations, echocardiographic parameters suggestive of PH were performed. The study population was stratified into two groups based on the presence (n = 98, 31%) or non-presence (n = 219, 69%) of PH. Also, we did logistic regression analyses for the independent predictors of the ICEs in AF patients. RESULTS Ischemic cerebrovascular events were significantly more frequent in the PH group than the non-PH group (n = 30, 13% vs. n = 18, 18%, p = 0.03). At univariable analysis, hypertension, diabetes mellitus, PH (OR = 0.23 [95% CI, 0.13-0.41], p = 0.005) and diastolic dysfunction were significantly related to ICE in AF patients. Moreover, at multivariable analysis, age, diabetes mellitus, PH (OR = 0.19 [95% CI, 0.10-0.36], p = 0.01), and diastolic dysfunction were predictive of ICE. CONCLUSIONS Pulmonary hypertension is likely associated with ischemic cerebrovascular events in patients with AF, requiring further investigation to determine its association.
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Affiliation(s)
- Serhat Karadavut
- Department of Cardiology, Kayseri Government Hospital, Kayseri, Turkey.
| | - Murat Cetin
- Department of Cardiology, Kayseri Government Hospital, Kayseri, Turkey
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Ding L, Weng S, Zhai Z, Zhou B, Qi Y, Yu F, Zhang H, Zhang S, Tang M. Association Between the Coronary Sinus Ostial Size and Atrioventricular Nodal Reentrant Tachycardia in Patients With Pulmonary Arterial Hypertension. Front Physiol 2022; 12:790077. [PMID: 35126179 PMCID: PMC8814530 DOI: 10.3389/fphys.2021.790077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/02/2021] [Indexed: 11/13/2022] Open
Abstract
AimsThe incidence of atrioventricular nodal reentrant tachycardia (AVNRT) is higher in pulmonary arterial hypertension (PAH) patients than in the general population. AVNRT is reportedly associated with a larger coronary sinus (CS) ostium (CSo). However, the correlation between AVNRT and CSo size in PAH patients is poorly investigated. We aimed to investigate the impact of CSo size on AVNRT and identify its risk factors in PAH.Methods and ResultsOf 102 PAH patients with catheter ablation of supraventricular tachycardia (SVT), twelve with a confirmed AVNRT diagnosis who underwent computed tomographic angiography were retrospectively enrolled as the study group. The control group (PAH without SVT, n = 24) was matched for sex and BMI at a 2:1 ratio. All baseline and imaging data were collected. Mean pulmonary artery pressure was not significantly different between the two groups (65.3 ± 16.8 vs. 64.5 ± 17.6 mmHg, P = 0.328). PAH patients with AVNRT were older (45.9 ± 14.8 vs. 32.1 ± 7.6 years, P = 0.025), had a larger right atrial volume (224.4 ± 129.6 vs. 165.3 ± 71.7 cm3, P = 0.044), larger CSo in the left anterior oblique (LAO) plane (18.6 ± 3.3 vs. 14.8 ± 4.0 mm, P = 0.011), and larger CSo surface area (2.08 ± 1.35 vs. 1.45 ± 0.73 cm2, P = 0.039) and were more likely to have a windsock-shape CS (75% vs. 16.7%, P = 0.001) than those without AVNRT. A linear correlation was shown between CSo diameter in the LAO-plane and the atrial fractionation of the ablation target for AVNRT (R2 = 0.622, P = 0.012).ConclusionAnatomical dilation of the CSo is a risk factor for AVNRT development in patients with PAH.
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Affiliation(s)
- Lei Ding
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sixian Weng
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhengqin Zhai
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Zhou
- Department of Cardiology, Laboratory of Heart Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yingjie Qi
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fengyuan Yu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongda Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Min Tang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Min Tang,
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Boyle TA, Daimee UA, Simpson CE, Kolb TM, Mathai SC, Akhtar T, Nyhan D, Calkins H, Spragg D. Left Atrial Ablation for the Management of Atrial Tachyarrhythmias in Patients with Pulmonary Hypertension: A Case Series. HeartRhythm Case Rep 2022; 8:275-279. [PMID: 35497477 PMCID: PMC9039084 DOI: 10.1016/j.hrcr.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Thomas A. Boyle
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
- Address reprint requests and correspondence: Dr Thomas A. Boyle, Division of Cardiology, Johns Hopkins Hospital, 600 North Wolfe St, Baltimore, MD 21287.
| | - Usama A. Daimee
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Catherine E. Simpson
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Todd M. Kolb
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Tauseef Akhtar
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Daniel Nyhan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - David Spragg
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
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Dusik M, Fingrova Z, Ambroz D, Jansa P, Linhart A, Havranek S. The Role of Pulmonary Artery Wedge Pressure on the Incidence of Atrial Fibrillation and Atrial Tachycardias in Patients With Isolated Pre-capillary Pulmonary Hypertens. Physiol Res 2021; 70:841-849. [PMID: 34717065 DOI: 10.33549/physiolres.934706] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Atrial fibrillation and atrial tachycardias (AF/AT) have been reported as a common condition in patients with pulmonary hypertension (PH). As yet, limited data exists about the significance of the borderline post-capillary pressure component on the occurrence of AF / AT in patients with isolated pre-capillary PH. We retrospectively studied the prevalence of AF / AT in 333 patients (mean age 61 ± 15 years, 44% males) with pre-capillary idiopathic / familiar pulmonary arterial hypertension, and inoperable chronic thromboembolic pulmonary hypertension. The prevalence of AF / AT was analyzed in different categories of pulmonary artery wedge pressure (PAWP). In the study population overall, the mean PAWP was 10.5 ± 3 mmHg, median of 11 mmHg, range 2-15 mmHg. AF / AT was diagnosed in 79 patients (24%). The proportion of AF / AT among patients with PAWP below the median (?11 mmHg) was lower than in subjects with PAWP between 12 and 15 mmHg, 30 (16%) vs. 46 (35%), p = 0.0001. Compared to the patients with PAWP?11 mmHg, subjects with PAWP between 12 and 15 mmHg were older (65 ± 13 years vs. 58 ± 16), with more prevalent arterial hyperte\nsion [100 (70%) vs. 106 (55%)] and diabetes mellitus [50 (35%) vs. 48 (25%)], showed larger size of the left atrium (42 ± 7 vs. 40 ± 6 mm), and higher values of right atrium pressure (12 ± 5 vs. 8 ± 5 mm Hg), p < 0.05 in all comparisons. The prevalence of AF / AT in the group studied increased with the growing post-capillary component.
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Affiliation(s)
- M Dusik
- 2nd Department of Medicine, Department of Cardiovascular Medicine, General University Hospital in Prague, 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic.
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Jamieson KL, Rose RA. New insights into ventricular arrhythmogenesis in a pure model of pulmonary arterial hypertension. Heart Rhythm 2021; 19:125-126. [PMID: 34628041 DOI: 10.1016/j.hrthm.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 11/24/2022]
Affiliation(s)
- K Lockhart Jamieson
- Libin Cardiovascular Institute, Department of Cardiac Sciences, Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert A Rose
- Libin Cardiovascular Institute, Department of Cardiac Sciences, Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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35
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Fernandes CJ, Calderaro D, Assad APL, Salibe-Filho W, Kato-Morinaga LT, Hoette S, Piloto B, Castro MA, Lisboa RP, da Silva TAF, Martins MDA, Alves-Jr JL, Jardim C, Terra-Filho M, de Souza R. Update on the Treatment of Pulmonary Arterial Hypertension. Arq Bras Cardiol 2021; 117:750-764. [PMID: 34709302 PMCID: PMC8528352 DOI: 10.36660/abc.20200702] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/13/2020] [Accepted: 11/04/2020] [Indexed: 11/28/2022] Open
Abstract
In the last decades, important advances have been made in the treatment of pulmonary arterial hypertension (PAH), a severe, progressive, incurable, and potentially fatal disease. For an adequate therapy, correct hemodynamic diagnosis and etiology classification are fundamental. Many etiologies - rheumatic disease, portal hypertension, congenital heart diseases, schistosomiasis - require specific measures, in addition to drug therapy for PAH. The specific therapy for PAH is based on medications that act on three pathophysiological pathways - prostacyclin, endothelin, and nitric oxide pathways. These drugs have multiple presentations (oral, intravenous, subcutaneous, and inhaled) and have changed the history of PAH. This review presents an overview of drug therapy strategies and different forms and peculiarities of PAH.
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Affiliation(s)
- Caio J. Fernandes
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Instituto do CâncerFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilInstituto do Câncer da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Daniela Calderaro
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Medicina Interdisciplinar - Divisão de Cardiologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Ana Paula Luppino Assad
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilDisciplina de Reumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - William Salibe-Filho
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Luciana Tamie Kato-Morinaga
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Susana Hoette
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Bruna Piloto
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Marcela Araújo Castro
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Roberta Pontes Lisboa
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Taysa Antonia Felix da Silva
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Murillo de Araújo Martins
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Jose L. Alves-Jr
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Instituto do CâncerFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilInstituto do Câncer da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Carlos Jardim
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Mario Terra-Filho
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
| | - Rogerio de Souza
- IncorFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Circulação Pulmonar - Divisão de Pneumologia – Incor - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasilHospital Sírio-Libanês, São Paulo, SP - Brasil
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Long term prognosis in patients with pulmonary hypertension undergoing catheter ablation for supraventricular tachycardia. Sci Rep 2021; 11:16176. [PMID: 34376719 PMCID: PMC8355112 DOI: 10.1038/s41598-021-95508-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 07/21/2021] [Indexed: 11/11/2022] Open
Abstract
Various forms of supraventricular tachycardia (SVT) occur in patients with severe pulmonary hypertension (PH). Despite the high efficacy of radiofrequency catheter ablation (RFCA) for SVT, insufficient data exist regarding patients with PH. Thirty SVTs in 23 PH patients (age 47 [35–60] years; mean pulmonary artery pressure 44 [32–50] mmHg) were analyzed. Procedural success rate, short- and long-term clinical outcomes, were evaluated during a median follow-up of 5.1 years. Single-procedure success rate was 83%; 94% (17/18) in typical atrial flutter, 73% (8/11) in atrial tachycardia (AT), and 100% (1/1) in atrioventricular nodal reentrant tachycardia. Antiarrhythmic drugs, serum brain natriuretic peptide levels and number of hospitalizations significantly decreased after RFCA than that before (p = 0.002, 0.04, and 0.002, respectively). Four patients had several procedures. After last RFCA, 12 patients had SVT and 8 patients died. Kaplan–Meier curves showed that patients with SVT after the last RFCA had a lower survival rate compared to those without (p = 0.0297). Multivariate analysis identified any SVT after the last RFCA as significant risk factor of mortality (hazard ratio: 9.31; p = 0.016). RFCA for SVT in patients with PH is feasible and effective in the short-term, but SVT is common during long-term follow-up and associated with lower survival.
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37
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Gelzinis TA. Pulmonary Hypertension in 2021: Part I-Definition, Classification, Pathophysiology, and Presentation. J Cardiothorac Vasc Anesth 2021; 36:1552-1564. [PMID: 34344595 DOI: 10.1053/j.jvca.2021.06.036] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/26/2021] [Accepted: 06/30/2021] [Indexed: 11/11/2022]
Abstract
The World Symposium on Pulmonary Hypertension (WSPH) was organized by the World Health Organization in 1973 in response to an increase in pulmonary arterial hypertension in Europe caused by aminorex, an appetite suppressant. The mandate of this meeting was to review the latest clinical and scientific research and to formulate recommendations to improve the diagnosis and management of pulmonary hypertension (PH).1 Since 1998, the WSPH has met every five years and in 2018, the sixth annual WSPH revised the hemodynamic definition of PH. This two-part series will review the updated definition, classification, pathophysiology, presentation, diagnosis, management, and perioperative management of patients with PH. In the first part of this series, the definition, classification, pathophysiology, and presentation will be reviewed.
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Margonato D, Ancona F, Ingallina G, Melillo F, Stella S, Biondi F, Boccellino A, Godino C, Margonato A, Agricola E. Tricuspid Regurgitation in Left Ventricular Systolic Dysfunction: Marker or Target? Front Cardiovasc Med 2021; 8:702589. [PMID: 34262955 PMCID: PMC8273168 DOI: 10.3389/fcvm.2021.702589] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/02/2021] [Indexed: 12/28/2022] Open
Abstract
Far from being historically considered a primary healthcare problem, tricuspid regurgitation (TR) has recently gained much attention from the scientific community. In fact, in the last years, robust evidence has emerged regarding the epidemiological impact of TR, whose prevalence seems to be similar to that of other valvulopathies, such as aortic stenosis, with an estimated up to 4% of people >75 years affected by at least moderate TR in the United States, and up to 23% among patients suffering from heart failure with reduced ejection fraction. This recurrent coexistence of left ventricular systolic dysfunction (LVSD) and TR is not surprising, considered the multiple etiologies of tricuspid valve disease. TR can complicate heart failure mostly as a functional disease, because of pulmonary hypertension (PH), subsequent to elevated left ventricular end-diastolic pressure, leading to right ventricular dilatation, and valve tethering. Moreover, the so-called "functional isolated" TR can occur, in the absence of PH, as a result of right atrial dilatation associated with atrial fibrillation, a common finding in patients with LVSD. Finally, TR can result as a iatrogenic consequence of transvalvular lead insertion, another frequent scenario in this cohort of patients. Nonetheless, despite the significant coincidence of these two conditions, their mutual relation, and the independent prognostic role of TR is still a matter of debate. Whether significant TR is just a marker for advanced left-heart disease, or a crucial potential therapeutical target, remains unclear. Aim of the authors in this review is to present an update concerning the epidemiological features and the clinical burden of TR in the context of LVSD, its prognostic value, and the potential benefit for early tricuspid intervention in patients affected by contemporary TR and LVSD.
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Affiliation(s)
- Davide Margonato
- Echocardiography Laboratory, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy.,Cardiology Department, University of Pavia, Pavia, Italy
| | - Francesco Ancona
- Echocardiography Laboratory, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Ingallina
- Echocardiography Laboratory, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Melillo
- Echocardiography Laboratory, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Stella
- Echocardiography Laboratory, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Federico Biondi
- Echocardiography Laboratory, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Boccellino
- Echocardiography Laboratory, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Cosmo Godino
- Department of Clinical Cardiology, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Margonato
- Department of Clinical Cardiology, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- Echocardiography Laboratory, Istituto di Ricerca a Cura e Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
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Zhou B, Zhu YJ, Zhai ZQ, Weng SX, Ma YZ, Yu FY, Qi YJ, Jiang YZ, Gao X, Xu XQ, Jiang X, Jing ZC, Tang M. Radiofrequency Catheter Ablation of Supraventricular Tachycardia in Patients With Pulmonary Hypertension: Feasibility and Long-Term Outcome. Front Physiol 2021; 12:674909. [PMID: 34220537 PMCID: PMC8249814 DOI: 10.3389/fphys.2021.674909] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/24/2021] [Indexed: 11/13/2022] Open
Abstract
Background Supraventricular tachycardia (SVT) occurs commonly and is strongly correlated with clinical deterioration in patients with pulmonary hypertension (PH). This study aimed to investigate the feasibility and long-term outcome of radiofrequency catheter ablation (RFCA) in PH patients with SVT. Materials and Methods Consecutive PH patients with SVT who were scheduled to undergo electrophysiological study and RFCA between September 2010 and July 2019 were included. The acute results and long-term success of RFCA were assessed after the procedure. Results In total, 71 PH patients with 76 episodes of SVT were analyzed. Cavotricuspid isthmus-dependent atrial flutter (n = 33, 43.5%) was the most common SVT type, followed by atrioventricular nodal reentrant tachycardia (n = 16, 21.1%). Of the 71 patients, 60 (84.5%) underwent successful electrophysiological study and were subsequently treated by RFCA. Among them, acute sinus rhythm was restored in 54 (90.0%) patients, and procedure-related complications were observed in 4 (6.7%) patients. Univariate logistic regression analysis showed that cavotricuspid isthmus-independent atrial flutter [odds ratio (OR) 25.00, 95% confidence interval (CI) 3.45–180.98, p = 0.001] and wider pulmonary artery diameter (OR 1.19, 95% CI 1.03–1.38; p = 0.016) were associated with RFCA failure. During a median follow-up of 36 (range, 3–108) months, 7 patients with atrial flutter experienced recurrence, yielding a 78.3% 3-year success rate for RFCA treatment. Conclusion The findings suggest that RFCA of SVT in PH patients is feasible and has a good long-term success rate. Cavotricuspid isthmus-independent atrial flutter and a wider PAD could increase the risk for ablation failure.
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Affiliation(s)
- Bin Zhou
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiology, Zhujiang Hospital, Laboratory of Heart Center, Southern Medical University, Guangzhou, China
| | - Yong-Jian Zhu
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zheng-Qin Zhai
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Si-Xian Weng
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ya-Zhe Ma
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Feng-Yuan Yu
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying-Jie Qi
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi-Zhou Jiang
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Gao
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Qi Xu
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Jiang
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Cheng Jing
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Min Tang
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Yildiz M, Kahraman S, Surgit O, Zencirkiran Agus H, Uygur B, Demir AR, Kalkan ME, Memic Sancar K, Oner E, Gurbak İ, Kalkan AK. Acute effects of inhaled iloprost on intracardiac conduction in patients with pulmonary arterial hypertension. Herz 2021; 47:158-165. [PMID: 34114047 DOI: 10.1007/s00059-021-05044-z] [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: 03/22/2021] [Revised: 04/17/2021] [Accepted: 04/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a severe, life-threatening disorder despite the availability of specific drug therapy. A lack of endogenous prostacyclin secondary to downregulation of prostacyclin synthase in PAH may contribute to vascular pathologies. Therefore, prostacyclin and its analogs including inhaled iloprost may decrease pulmonary arterial pressure and ventricular pressure. METHODS Here, we studied that acute effects of iloprost used in pulmonary vasoreactivity testing on the intracardiac conduction system in patients with PAH. A total of 35 (15 idiopathic PAH, 20 congenital heart disease) patients with PAH were included in this prospective study. Patients were divided into two groups: 22 patients with negative pulmonary vasoreactivity in group 1 and 13 with positive pulmonary vasoreactivity in group 2. Electrophysiological parameters including basic cycle length, atrium-His (AH) interval, His-ventricle (HV) interval, PR interval, QT interval, QRS duration, Wenckebach period, and sinus node recovery time (SNRT) were evaluated before and after pulmonary vasoreactivity testing in both groups. RESULTS The AH interval (81 [74-93]; 80 [65.5-88], p = 0.019) and SNRT (907.7 ± 263.4; 854.0 ± 288.04, p = 0.027) was significantly decreased after pulmonary vasoreactivity testing. Mean right atrium pressure was found to be correlated with baseline AH (r = 0.371, p = 0.031) and SNRT (r = 0.353, p = 0.037). CONCLUSION Inhaled iloprost can improve cardiovascular performance in the presence of PAH, primarily through a reduction in right ventricular afterload and interventricular pressure. Decreased pressure on the interventricular septum and ventricles leads to conduction system normalization including of the AH interval and SNRT due to resolution of inflammation and edema.
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Affiliation(s)
- Mustafa Yildiz
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, University of Health Sciences, İstasyon Mah. Turgut Özal Bulvarı No:11 Küçükçekmece, Istanbul, Turkey
| | - Serkan Kahraman
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, University of Health Sciences, İstasyon Mah. Turgut Özal Bulvarı No:11 Küçükçekmece, Istanbul, Turkey
| | - Ozgur Surgit
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, University of Health Sciences, İstasyon Mah. Turgut Özal Bulvarı No:11 Küçükçekmece, Istanbul, Turkey
| | - Hicaz Zencirkiran Agus
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, University of Health Sciences, İstasyon Mah. Turgut Özal Bulvarı No:11 Küçükçekmece, Istanbul, Turkey.
| | - Begum Uygur
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, University of Health Sciences, İstasyon Mah. Turgut Özal Bulvarı No:11 Küçükçekmece, Istanbul, Turkey
| | - Ali R Demir
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, University of Health Sciences, İstasyon Mah. Turgut Özal Bulvarı No:11 Küçükçekmece, Istanbul, Turkey
| | - Mehmet E Kalkan
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, University of Health Sciences, İstasyon Mah. Turgut Özal Bulvarı No:11 Küçükçekmece, Istanbul, Turkey
| | - Kadriye Memic Sancar
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, University of Health Sciences, İstasyon Mah. Turgut Özal Bulvarı No:11 Küçükçekmece, Istanbul, Turkey
| | - Ender Oner
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, University of Health Sciences, İstasyon Mah. Turgut Özal Bulvarı No:11 Küçükçekmece, Istanbul, Turkey
| | - İsmail Gurbak
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, University of Health Sciences, İstasyon Mah. Turgut Özal Bulvarı No:11 Küçükçekmece, Istanbul, Turkey
| | - Ali K Kalkan
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, University of Health Sciences, İstasyon Mah. Turgut Özal Bulvarı No:11 Küçükçekmece, Istanbul, Turkey
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Stam K, Clauss S, Taverne YJHJ, Merkus D. Chronic Thromboembolic Pulmonary Hypertension - What Have We Learned From Large Animal Models. Front Cardiovasc Med 2021; 8:574360. [PMID: 33937352 PMCID: PMC8085273 DOI: 10.3389/fcvm.2021.574360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 03/08/2021] [Indexed: 12/21/2022] Open
Abstract
Chronic thrombo-embolic pulmonary hypertension (CTEPH) develops in a subset of patients after acute pulmonary embolism. In CTEPH, pulmonary vascular resistance, which is initially elevated due to the obstructions in the larger pulmonary arteries, is further increased by pulmonary microvascular remodeling. The increased afterload of the right ventricle (RV) leads to RV dilation and hypertrophy. This RV remodeling predisposes to arrhythmogenesis and RV failure. Yet, mechanisms involved in pulmonary microvascular remodeling, processes underlying the RV structural and functional adaptability in CTEPH as well as determinants of the susceptibility to arrhythmias such as atrial fibrillation in the context of CTEPH remain incompletely understood. Several large animal models with critical clinical features of human CTEPH and subsequent RV remodeling have relatively recently been developed in swine, sheep, and dogs. In this review we will discuss the current knowledge on the processes underlying development and progression of CTEPH, and on how animal models can help enlarge understanding of these processes.
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Affiliation(s)
- Kelly Stam
- Department of Cardiology, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sebastian Clauss
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University Munich, Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Daphne Merkus
- Department of Cardiology, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands.,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance, Munich, Germany
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Reddy SA, Nethercott SL, Khialani BV, Grace AA, Martin CA. Management of arrhythmias in pulmonary hypertension. J Interv Card Electrophysiol 2021; 62:219-229. [DOI: 10.1007/s10840-021-00988-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/28/2021] [Indexed: 12/24/2022]
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Andersen MØ, Diederichsen SZ, Svendsen JH, Carlsen J. Assessment of cardiac arrhythmias using long-term continuous monitoring in patients with pulmonary hypertension. Int J Cardiol 2021; 334:110-115. [PMID: 33819493 DOI: 10.1016/j.ijcard.2021.03.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/17/2021] [Accepted: 03/19/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cardiac arrhythmias are considered a prominent phenomenon in patients with pulmonary hypertension (PH). Older studies reported that 8% to 35% of patients with PH had supraventricular tachycardia (SVT), associated with adverse outcomes. Still, these arrhythmias have only been investigated via short-term monitoring or limited electrocardiogram recordings. METHODS Patients without previous arrhythmias diagnosed with PH at a tertiary facility received an insertable cardiac monitor as part of a prospective cohort study. Baseline assessments included World Health Organization functional class, six-minute walk test, echocardiography, and cardiac magnetic resonance imaging. RESULTS Thirty-four patients with PH were included. Twenty-four patients had pulmonary arterial hypertension (PAH) and 10 had chronic thromboembolic PH (CTEPH). During 46 patient-years of continuous monitoring (median: 594 (range: 334-654) days per patient), 70 arrhythmia episodes were recorded in 13 patients (38%), with a median of two (range: 1-3) episodes and an arrhythmic burden median of 1.6 (range: 0.1-228) minutes per patient. SVTs were the most common arrhythmias, with 16% of episodes being atrial fibrillation and 84% being other types of SVTs. Additionally, three patients experienced bradycardias, including one resulting in syncope and subsequent pacemaker implantation. None of the patients had sustained ventricular arrhythmias. CONCLUSIONS Arrhythmias were seen in 38% of contemporary patients with PH during long-term continuous monitoring; however, the vast majority of episodes were short and self-limiting. Modern therapy may alleviate the development of arrhythmias in stable patients with PH. This study is the first study to deploy long-term continuous monitoring in patients with PH.
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Affiliation(s)
- Mads Ørbæk Andersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, 9- Blegdamsvej, Copenhagen, Denmark
| | - Søren Zöga Diederichsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, 9- Blegdamsvej, Copenhagen, Denmark
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, 9- Blegdamsvej, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, Copenhagen 2200, Denmark
| | - Jørn Carlsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, 9- Blegdamsvej, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, Copenhagen 2200, Denmark.
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Coleman RD, Chartan CA, Mourani PM. Intensive care management of right ventricular failure and pulmonary hypertension crises. Pediatr Pulmonol 2021; 56:636-648. [PMID: 33561307 DOI: 10.1002/ppul.24776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 04/03/2020] [Indexed: 01/22/2023]
Abstract
Pulmonary hypertension (PH), an often unrelenting disease that carries with it significant morbidity and mortality, affects not only the pulmonary vasculature but, in turn, the right ventricle as well. The survival of patients with PH is closely related to the right ventricular function. Therefore, having an understanding of how to manage right ventricular failure (RVF) and acute pulmonary hypertensive crises is imperative for clinicians who encounter these patients. This review addresses the management of these patients in detail, addressing: (a) the pathophysiology of RVF, (b) intensive care monitoring of these patients in the intensive care unit, (c) imaging of the right ventricle, (d) intubation and mechanical ventilation, (e) inotrope and vasopressor selection, (f) pulmonary vasodilator use, (g) interventional and surgical procedures for the acutely failing right ventricle, and (h) mechanical support for RVF.
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Affiliation(s)
- Ryan D Coleman
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Section of Pulmonary Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Corey A Chartan
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Section of Pulmonary Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Peter M Mourani
- Section of Critical Care Medicine and Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
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Abstract
Atrial fibrillation is associated with aging, obesity, heart disease, diabetes, and/or hypertension. Recent evidence suggests that parenchymal and vascular lung diseases increase atrial fibrillation risk. We review the epidemiology, clinical features, pathophysiologic mechanisms, and treatment implications of atrial fibrillation associated with diseases of the lungs and their vasculature, especially pulmonary hypertension. We also consider other features of pulmonary disease-associated atrial fibrillation. A key mediator of these conditions is right heart disease and right atrial remodeling. We pay particular attention to the pathophysiology and treatment challenges in atrial fibrillation associated with right heart disease induced by pulmonary diseases, including pulmonary hypertension.
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Affiliation(s)
- Roddy Hiram
- Department of Medicine, Montreal Heart Institute (MHI), Université de Montréal, Montréal, Quebec, Canada.
| | - Steeve Provencher
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec, Canada; Department of medicine, Université Laval, 2325 rue de l'Universite, Montréal, Quebec G1V 0A6, Canada
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Fingrova Z, Ambroz D, Jansa P, Kuchar J, Lindner J, Kunstyr J, Aschermann M, Linhart A, Havranek S. The prevalence and clinical outcome of supraventricular tachycardia in different etiologies of pulmonary hypertension. PLoS One 2021; 16:e0245752. [PMID: 33471824 PMCID: PMC7817034 DOI: 10.1371/journal.pone.0245752] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 01/06/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose Patients with pulmonary hypertension (PH) frequently suffer from supraventricular tachycardias (SVT). The main purpose of our study was to identify the cumulative incidence of SVT in patients with different etiologies of PH. The secondary objective was to analyse the clinical impact of SVT. Methods We retrospectively studied the prevalence of SVT and the clinical outcome in 755 patients (41% males; 60 ± 15 years; mean follow-up 3.8 ± 2.8 years) with PH of different etiologies. The prevalence of SVT was analysed separately in isolated pre-capillary PH (Ipc-PH) and in patients with combined post- and pre-capillary PH (Cpc-PH). Results The prevalence of SVT in the Ipc-PH group (n = 641) was 25% (n = 162). The most prevalent arrhythmias were atrial fibrillation followed by a typical atrial flutter (17% and 4.4% of all Icp-PH patients). An excessive prevalence of SVT was found in patients with pulmonary arterial hypertension associated with congenital heart disease (35%, p = 0.01). Out of the overall study population, Cpc-PH was present in 114 (15%) patients. Patients with Cpc-PH manifested a higher prevalence of SVT than subjects with Ipc-PH (58; 51% vs. 162; 25%; p <0.0001) and were more likely to have persistent or permanent atrial fibrillation (38; 29% vs. 61; 10%; p <0.0001). Parameters significantly associated with mortality in a multivariate analysis included age, male gender, functional exercise capacity and right atrial diameter (p < 0.05). Neither diagnosis of SVT nor type of arrhythmia predicted mortality. Conclusions The study detected a significant prevalence of SVT in the population of PH of different origins. Different spectrum and prevalence of arrhythmia might be expected in different etiologies of PH. Patients with an elevated post-capillary pressure showed a higher arrhythmia prevalence, predominantly due to an excessive number of atrial fibrillations. The diagnosis of SVT was not associated with mortality.
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Affiliation(s)
- Zdenka Fingrova
- 1Faculty of Medicine, 2 Department of Medicine-Department of Cardiovascular Medicine, General University Hospital, Charles University, Prague, Czech Republic
| | - David Ambroz
- 1Faculty of Medicine, 2 Department of Medicine-Department of Cardiovascular Medicine, General University Hospital, Charles University, Prague, Czech Republic
| | - Pavel Jansa
- 1Faculty of Medicine, 2 Department of Medicine-Department of Cardiovascular Medicine, General University Hospital, Charles University, Prague, Czech Republic
| | - Jan Kuchar
- 1Faculty of Medicine, 2 Department of Medicine-Department of Cardiovascular Medicine, General University Hospital, Charles University, Prague, Czech Republic
- Regional Hospital in Tabor, Tabor, Czech Republic
| | - Jaroslav Lindner
- 1 Faculty of Medicine, 2 Department of Surgery–Department of Cardiovascular Surgery, General University Hospital, Charles University, Prague, Czech Republic
| | - Jan Kunstyr
- 1 Faculty of Medicine, Department of Anaesthesiology, Resuscitation and Intensive Medicine, General University Hospital, Charles University, Prague, Czech Republic
| | - Michael Aschermann
- 1Faculty of Medicine, 2 Department of Medicine-Department of Cardiovascular Medicine, General University Hospital, Charles University, Prague, Czech Republic
| | - Ales Linhart
- 1Faculty of Medicine, 2 Department of Medicine-Department of Cardiovascular Medicine, General University Hospital, Charles University, Prague, Czech Republic
| | - Stepan Havranek
- 1Faculty of Medicine, 2 Department of Medicine-Department of Cardiovascular Medicine, General University Hospital, Charles University, Prague, Czech Republic
- * E-mail:
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Inampudi C, Tedford RJ, Hemnes AR, Hansmann G, Bogaard HJ, Koestenberger M, Lang IM, Brittain EL. Treatment of right ventricular dysfunction and heart failure in pulmonary arterial hypertension. Cardiovasc Diagn Ther 2020; 10:1659-1674. [PMID: 33224779 PMCID: PMC7666956 DOI: 10.21037/cdt-20-348] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/13/2020] [Indexed: 01/09/2023]
Abstract
Right heart dysfunction and failure is the principal determinant of adverse outcomes in patients with pulmonary arterial hypertension (PAH). In addition to right ventricular (RV) dysfunction, systemic congestion, increased afterload and impaired myocardial contractility play an important role in the pathophysiology of RV failure. The behavior of the RV in response to the hemodynamic overload is primarily modulated by the ventricular interaction and its coupling to the pulmonary circulation. The presentation can be acute with hemodynamic instability and shock or chronic producing symptoms of systemic venous congestion and low cardiac output. The prognostic factors associated with poor outcomes in hospitalized patients include systemic hypotension, hyponatremia, severe tricuspid insufficiency, inotropic support use and the presence of pericardial effusion. Effective therapeutic management strategies involve identification and effective treatment of the triggering factors, improving cardiopulmonary hemodynamics by optimization of volume to improve diastolic ventricular interactions, improving contractility by use of inotropes, and reducing afterload by use of drugs targeting pulmonary circulation. The medical therapies approved for PAH act primarily on the pulmonary vasculature with secondary effects on the right ventricle. Mechanical circulatory support as a bridge to transplantation has also gained traction in medically refractory cases. The current review was undertaken to summarize recent insights into the evaluation and treatment of RV dysfunction and failure attributable to PAH.
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Affiliation(s)
- Chakradhari Inampudi
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Harm-Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Irene Marthe Lang
- Division of Cardiology, Department of Medicine, Medical University of Vienna, Vienna
| | - Evan L. Brittain
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Translational and Clinical Cardiovascular Research Center, Nashville, TN, USA
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Majos-Karwacka E, Kraska A, Kowalik I, Smolis-Bak E, Lipiec P, Kasprzak J, Szwed H, Dabrowski R. No effects of cardiac resynchronization therapy and right ventricular pacing on the right ventricle in patients with heart failure and atrial fibrillation. SCAND CARDIOVASC J 2020; 55:15-21. [PMID: 32954833 DOI: 10.1080/14017431.2020.1820565] [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] [Indexed: 10/23/2022]
Abstract
BACKGROUND The right ventricle (RV) function is crucial in heart failure with reduced ejection fraction (HFrEF), especially in patients with atrial fibrillation (AF). Aims. To assess the RV structure and function in patients with HFrEF, permanent atrial fibrillation (AF), cardiac resynchronization therapy (CRT) and RV pacing (RVp) with two- and three-dimensional echocardiography. Methods. Patients with ischemic HFrEF (NYHA II-III; LVEF ≤40%) were enrolled. The studied groups were: sinus rhythm (SR, control); AF and no implanted devices - AF/0; AF and CRT - AF/CRT; AF and RVp - AF/RVp. Two- and three-dimensional echocardiographic parameters of RV structure and function were analyzed in study groups. Results. The study included a group of 126 patients: n = 32 with SR, n = 28 with AF/0, n = 25 with AF/CRT and n = 41 with AF/RVp. Results were worse in AF groups than in SR: right ventricular ejection fraction, %, mean (SD): SR - 48.2 (7.5), AF/0 - 36.5 (6.5), AF/CRT - 38.3 (7.6), AF/RVp - 37.1 (7.7), p < .001. Other parameters lower in AF groups than in SR were: RV end-systolic volume, longitudinal strain of the free wall and tricuspid lateral annular systolic velocity. There were no differences between groups with AF and CRT and RV pacing in other analyzed parameters between AF groups and SR. Conclusions. In heart failure with reduced left ventricular ejection fraction and atrial fibrillation right ventricular pacing and cardiac resynchronization therapy were not associated with modified right ventricular function. Further prospective studies are needed to evaluate prognostic significance of these results.
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Affiliation(s)
- Ewa Majos-Karwacka
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, Warsaw, Poland
| | - Alicja Kraska
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, Warsaw, Poland
| | - Ilona Kowalik
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, Warsaw, Poland
| | - Edyta Smolis-Bak
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, Warsaw, Poland
| | - Piotr Lipiec
- Department of Cardiology, Medical University of Lodz, Lodz, Poland
| | | | - Hanna Szwed
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, Warsaw, Poland
| | - Rafal Dabrowski
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, Warsaw, Poland
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Jansen SMA, Huis In 't Veld AE, Jacobs W, Grotjohan HP, Waskowsky M, van der Maten J, van der Weerdt A, Hoekstra R, Overbeek MJ, Mollema SA, Tolen PHCG, Hassan El Bouazzaoui LH, Vriend JWJ, Roorda JMM, de Nooijer R, van der Lee I, Voogel BAJ, Peels K, Macken T, Aerts JM, Vonk Noordegraaf A, Handoko ML, de Man FS, Bogaard HJ. Noninvasive Prediction of Elevated Wedge Pressure in Pulmonary Hypertension Patients Without Clear Signs of Left-Sided Heart Disease: External Validation of the OPTICS Risk Score. J Am Heart Assoc 2020; 9:e015992. [PMID: 32750312 PMCID: PMC7792270 DOI: 10.1161/jaha.119.015992] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Although most newly presenting patients with pulmonary hypertension (PH) have elevated pulmonary artery wedge pressure, identification of so‐called postcapillary PH can be challenging. A noninvasive tool predicting elevated pulmonary artery wedge pressure in patients with incident PH may help avoid unnecessary invasive diagnostic procedures. Methods and Results A combination of clinical data, ECG, and echocardiographic parameters was used to refine a previously developed left heart failure risk score in a retrospective cohort of pre‐ and postcapillary PH patients. This updated score (renamed the OPTICS risk score) was externally validated in a prospective cohort of patients from 12 Dutch nonreferral centers the OPTICS network. Using the updated OPTICS risk score, the presence of postcapillary PH could be predicted on the basis of body mass index ≥30, diabetes mellitus, atrial fibrillation, dyslipidemia, history of valvular surgery, sum of SV1 (deflection in V1 in millimeters) and RV6 (deflection in V6 in millimeters) on ECG, and left atrial dilation. The external validation cohort included 81 postcapillary PH patients and 66 precapillary PH patients. Using a predefined cutoff of >104, the OPTICS score had 100% specificity for postcapillary PH (sensitivity, 22%). In addition, we investigated whether a high probability of heart failure with preserved ejection fraction, assessed by the H2FPEF score (obesity, atrial fibrillation, age >60 yrs, ≥2 antihypertensives, E/e' >9, and pulmonary artery systolic pressure by echo >35 mmHg), similarly predicted the presence of elevated pulmonary artery wedge pressure. High probability of heart failure with preserved ejection fraction (H2FPEF score ≥6) was less specific for postcapillary PH. Conclusions In a community setting, the OPTICS risk score can predict elevated pulmonary artery wedge pressure in PH patients without clear signs of left‐sided heart disease. The OPTICS risk score may be used to tailor the decision to perform invasive diagnostic testing.
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Affiliation(s)
- Samara M A Jansen
- Department of Pulmonology VU University Medical Center Amsterdam The Netherlands
| | | | - Wouter Jacobs
- Department of Pulmonology of the Martini Ziekenhuis Groningen Groningen The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Kathinka Peels
- Catharina Ziekenhuis Eindhoven Eindhoven The Netherlands
| | - Thomas Macken
- Jeroen Bosch ziekenhuis Den Bosch Hertogenbosch The Netherlands
| | | | | | - M Louis Handoko
- Department of Cardiology VU University Medical Center Amsterdam The Netherlands
| | - Frances S de Man
- Department of Pulmonology VU University Medical Center Amsterdam The Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonology VU University Medical Center Amsterdam The Netherlands
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Prevalence of right ventricular dysfunction and prognostic significance in heart failure with preserved ejection fraction. Int J Cardiovasc Imaging 2020; 37:255-266. [PMID: 32737707 PMCID: PMC7878207 DOI: 10.1007/s10554-020-01953-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/22/2020] [Indexed: 12/01/2022]
Abstract
There is a paucity of data characterizing right ventricular performance in heart failure with preserved ejection fraction (HFpEF) using the gold standard of cardiovascular magnetic resonance imaging (CMR). We aimed to assess the proportion of right ventricular systolic dysfunction (RVD) in HFpEF and the relation to clinical outcomes. As part of a single-centre, prospective, observational study, 183 subjects (135 HFpEF, and 48 age- and sex-matched controls) underwent extensive characterization with CMR. transthoracic echocardiography, blood sampling and six-minute walk testing. Patients were followed for the composite endpoint of death or HF hospitalization. RVD (defined as right ventricular ejection fraction < 47%) controls was present in 19% of HFpEF. Patients with RVD presented more frequently with lower systolic blood pressure, atrial fibrillation, radiographic evidence of pulmonary congestion and raised cardiothoracic ratio and larger right ventricular volumes. During median follow-up of 1429 days, 47% (n = 64) of HFpEF subjects experienced the composite endpoint of death (n = 22) or HF hospitalization (n = 42). RVD was associated with an increased risk of composite events (Log-Rank p = 0.001). In multivariable Cox regression analysis, RVD was an independent predictor of adverse outcomes (adjusted Hazard Ratio [HR] 3.946, 95% CI 1.878–8.290, p = 0.0001) along with indexed extracellular volume (HR 1.742, CI 1.176–2.579, p = 0.006) and E/E’ (HR 1.745, CI 1.230–2.477, p = 0.002). RVD as assessed by CMR is prevalent in nearly one-fifth of HFpEF patients and is independently associated with death and/or hospitalization with HF. The trial was registered retrospectively on ClinicalTrials.gov (Identifier: NCT03050593). The date of registration was February 06, 2017.
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