1
|
Corda A, Corda F, Pentcheva P, Puci M, Mollica A, Gomez Ochoa P, Dabbagh T, Pinna Parpaglia ML. The echocardiographic pulmonary to left atrial ratio: A noninvasive variable for the hemodynamic classification of pulmonary hypertension in dogs. J Vet Intern Med 2024; 38:2064-2075. [PMID: 38715386 PMCID: PMC11256189 DOI: 10.1111/jvim.17097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 04/18/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND Hemodynamic classification of pulmonary hypertension (PH) has important clinical implications. However, only a few echocardiographic variables have been used to hemodynamically classify PH in dogs. OBJECTIVE To evaluate the echocardiographic pulmonary to left atrial ratio index (ePLAR) in dogs with PH. ANIMALS Forty-six dogs with intermediate to high probability of PH. METHODS Cross-sectional study. Variables were compared between dogs with precapillary PH [PrePH (n = 24)] vs postcapillary PH [PostPH (n = 22)], and with combined PH [CombPH (n = 14)] vs isolated PH [IsoPH (n = 8)] using the t-, Mann-Whitney, Pearson's Chi, or Fisher's exact test. The receiver operating characteristic curve and Youden index were used to identify the optimal ePLAR cutoff value to differentiate among the groups, intraclass correlation coefficients (ICC) were used to determine the reliability of measurements. RESULTS The mean (SD) ePLAR of the PrePH was higher than that of the PostPH group [0.36 (0.13) vs 0.26 (0.09), respectively; P = .005]. The median (interquartile range) ePLAR of the CombPH was higher than that of the IsoPH subgroup [0.29 (0.24-0.38), vs 0.20 (0.16-0.23), respectively; P = .001]. The best cutoff value of ePLAR for identifying IsoPH was <0.245 [AUC at cutoff point = 0.86; sensitivity (95% confidence interval [CI]) = 0.71 (0.47-0.95); specificity (95% CI) = 1 (0.76-1)]. The ICC analysis indicated a high degree of reliability. CONCLUSIONS AND CLINICAL IMPORTANCE ePLAR can be considered a valid noninvasive variable to hemodynamically classify PH in dogs with an intermediate to high probability of PH. Assessment of ePLAR can be useful in the therapeutic management of PH in dogs.
Collapse
Affiliation(s)
- Andrea Corda
- Veterinary Teaching Hospital, Department of Veterinary MedicineUniversity of SassariSassariItaly
| | - Francesca Corda
- Veterinary Teaching Hospital, Department of Veterinary MedicineUniversity of SassariSassariItaly
| | - Plamena Pentcheva
- Veterinary Teaching Hospital, Department of Veterinary MedicineUniversity of SassariSassariItaly
| | - Mariangela Puci
- Clinical Epidemiology and Medical Statistic Unit, Department of Medicine, Surgery and PharmacyUniversity of SassariSassariItaly
| | - Alessandra Mollica
- Veterinary Teaching Hospital, Department of Veterinary MedicineUniversity of SassariSassariItaly
| | | | - Thouraya Dabbagh
- Veterinary Teaching Hospital, Department of Veterinary MedicineUniversity of SassariSassariItaly
| | | |
Collapse
|
2
|
Tsolaki V, Zakynthinos GE, Karavidas N, Vazgiourakis V, Papanikolaou J, Parisi K, Zygoulis P, Makris D, Zakynthinos E. Comprehensive temporal analysis of right ventricular function and pulmonary haemodynamics in mechanically ventilated COVID-19 ARDS patients. Ann Intensive Care 2024; 14:25. [PMID: 38345712 PMCID: PMC10861421 DOI: 10.1186/s13613-024-01241-1] [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: 08/30/2023] [Accepted: 01/02/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Cardiac injury is frequently reported in COVID-19 patients, the right ventricle (RV) is mostly affected. We systematically evaluated the cardiac function and longitudinal changes in severe COVID-19 acute respiratory distress syndrome (ARDS) admitted to the intensive care unit (ICU) and assessed the impact on survival. METHODS We prospectively performed comprehensive echocardiographic analysis on mechanically ventilated COVID-19 ARDS patients, using 2D/3D echocardiography. We defined left ventricular (LV) systolic dysfunction as ejection fraction (EF) < 40%, or longitudinal strain (LS) > - 18% and right ventricular (RV) dysfunction if two indices among fractional area change (FAC) < 35%, tricuspid annulus systolic plane excursion (TAPSE) < 1.6 cm, RV EF < 44%, RV-LS > - 20% were present. RV afterload was assessed from pulmonary artery systolic pressure (PASP), PASP/Velocity Time Integral in the right ventricular outflow tract (VTIRVOT) and pulmonary acceleration time (PAcT). TAPSE/PASP assessed the right ventriculoarterial coupling (VACR). RESULTS Among 176 patients included, RV dysfunction was common (69%) (RV-EF 41.1 ± 1.3%; RV-FAC 36.6 ± 0.9%, TAPSE 20.4 ± 0.4mm, RV-LS:- 14.4 ± 0.4%), usually accompanied by RV dilatation (RVEDA/LVEDA 0.82 ± 0.02). RV afterload was increased in most of the patients (PASP 33 ± 1.1 mmHg, PAcT 65.3 ± 1.5 ms, PASP/VTIRVOT, 2.29 ± 0.1 mmHg/cm). VACR was 0.8 ± 0.06 mm/mmHg. LV-EF < 40% was present in 21/176 (11.9%); mean LV-EF 57.8 ± 1.1%. LV-LS (- 13.3 ± 0.3%) revealed a silent LV impairment in 87.5%. A mild pericardial effusion was present in 70(38%) patients, more frequently in non-survivors (p < 0.05). Survivors presented significant improvements in respiratory physiology during the 10th ICU-day (PaO2/FiO2, 231.2 ± 11.9 vs 120.2 ± 6.7 mmHg; PaCO2, 43.1 ± 1.2 vs 53.9 ± 1.5 mmHg; respiratory system compliance-CRS, 42.6 ± 2.2 vs 27.8 ± 0.9 ml/cmH2O, all p < 0.0001). Moreover, survivors presented significant decreases in RV afterload (PASP: 36.1 ± 2.4 to 20.1 ± 3 mmHg, p < 0.0001, PASP/VTIRVOT: 2.5 ± 1.4 to 1.1 ± 0.7, p < 0.0001 PAcT: 61 ± 2.5 to 84.7 ± 2.4 ms, p < 0.0001), associated with RV systolic function improvement (RVEF: 36.5 ± 2.9% to 46.6 ± 2.1%, p = 0.001 and RV-LS: - 13.6 ± 0.7% to - 16.7 ± 0.8%, p = 0.001). In addition, RV dilation subsided in survivors (RVEDA/LVEDA: 0.8 ± 0.05 to 0.6 ± 0.03, p = 0.001). Day-10 CRS correlated with RV afterload (PASP/VTIRVOT, r: 0.535, p < 0.0001) and systolic function (RV-LS, 0.345, p = 0.001). LV-LS during the 10th ICU-day, while ΔRV-LS and ΔPASP/RVOTVTI were associated with survival. CONCLUSIONS COVID-19 improvements in RV function, RV afterload and RV-PA coupling at day 10 were associated with respiratory function and survival.
Collapse
Affiliation(s)
- Vasiliki Tsolaki
- Critical Care Department, Faculty of Medicine, University Hospital of Larissa, University of Thessaly, Mezourlo, 41110, Larissa, Greece
| | | | - Nikitas Karavidas
- Critical Care Department, Faculty of Medicine, University Hospital of Larissa, University of Thessaly, Mezourlo, 41110, Larissa, Greece
| | - Vasileios Vazgiourakis
- Critical Care Department, Faculty of Medicine, University Hospital of Larissa, University of Thessaly, Mezourlo, 41110, Larissa, Greece
| | - John Papanikolaou
- Department of Cardiology, General Hospital of Trikala, Karditsis 56, 42131, Trikala, Thessaly, Greece
| | - Kyriaki Parisi
- Critical Care Department, Faculty of Medicine, University Hospital of Larissa, University of Thessaly, Mezourlo, 41110, Larissa, Greece
| | - Paris Zygoulis
- Critical Care Department, Faculty of Medicine, University Hospital of Larissa, University of Thessaly, Mezourlo, 41110, Larissa, Greece
| | - Demosthenes Makris
- Critical Care Department, Faculty of Medicine, University Hospital of Larissa, University of Thessaly, Mezourlo, 41110, Larissa, Greece
| | - Epaminondas Zakynthinos
- Critical Care Department, Faculty of Medicine, University Hospital of Larissa, University of Thessaly, Mezourlo, 41110, Larissa, Greece.
| |
Collapse
|
3
|
Vedage NA, Forfia PR, Grafstrom A, Vaidya A. Virtual Echocardiography Screening Tool Identifies Pulmonary Arterial Hypertension Significantly Earlier Than High-Risk Clinical Diagnosis. Am J Cardiol 2023; 201:328-334. [PMID: 37406576 DOI: 10.1016/j.amjcard.2023.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 07/07/2023]
Abstract
Pulmonary arterial hypertension (PAH) is often a progressive, fatal disease. Because of nonspecificity of symptoms and limited awareness of PAH, patients are often diagnosed and referred late to accredited pulmonary hypertension (PH) centers, contributing to worsening survival and overall prognosis. The objective of the present study was to determine if the virtual echocardiography screening tool (VEST), a simple scoring system using routinely reported echocardiographic metrics, could capture earlier diagnoses of PAH before clinical recognition and referral to expert PH centers. This study is a retrospective analysis of 132 patients with PAH evaluated consecutively at 2 accredited referral PH centers. VEST scores and time to evaluation at PH center were quantified based on the first available echocardiogram before referral. Clinical risk assessment was calculated at initial evaluation by the PH center using the REVEAL (Registry to Evaluate Early and Long-term PAH Disease Management) 2.0 calculator. An overwhelming majority (93%) of the study participants had markedly abnormal VEST scores predictive of PAH before evaluation at a PH referral center. The median delay from VEST to evaluation was >6 months at 206 days (quartile 1, quartile 3: 55, 757). At initial evaluation, 72% were intermediate or high-risk based on REVEAL 2.0 risk assessment. In conclusion, we propose that VEST is a powerful yet simple scoring tool that can capture high-risk patients with PAH, prompting earlier diagnosis and referrals to accredited PH centers, and allowing for earlier expert implementation of PH medical therapies.
Collapse
Affiliation(s)
- Natasha A Vedage
- Division of Cardiology, Pulmonary Hypertension, Right Heart Failure and CTEPH Program, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Paul R Forfia
- Division of Cardiology, Pulmonary Hypertension, Right Heart Failure and CTEPH Program, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Alexander Grafstrom
- Division of Cardiology, Pulmonary Hypertension, Right Heart Failure and CTEPH Program, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Anjali Vaidya
- Division of Cardiology, Pulmonary Hypertension, Right Heart Failure and CTEPH Program, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania.
| |
Collapse
|
4
|
Albinni S, Heno J, Pavo I, Kitzmueller E, Marx M, Michel-Behnke I. Macitentan in the Young-Mid-term Outcomes of Patients with Pulmonary Hypertensive Vascular Disease treated in a Pediatric Tertiary Care Center. Paediatr Drugs 2023; 25:467-481. [PMID: 37269500 PMCID: PMC10284929 DOI: 10.1007/s40272-023-00573-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Pulmonary hypertension (PH) is a severe hemodynamic condition with high morbidity and mortality. Approved targeted therapies are limited for pediatric subjects, and treatments are widely adopted from adult algorithms. Macitentan is a safe and effective drug used for adult PH, but data on pediatric patients are limited. In this prospective single-center study, we investigated mid- and long-term effects of macitentan in children with advanced pulmonary hypertensive vascular disease. METHODS Twenty-four patients were enrolled in the study for treatment with macitentan. Efficacy was determined by echo parameters and brain natriuretic peptide levels (BNP) at 3 months and 1 year. For detailed analysis, the entire cohort was subgrouped into patients with congenital heart disease-related PH (CHD-PH) and non-CHD-PH patients, respectively. RESULTS Mean age of the patients was 10.7 ± 7.6 years; median observation period was 36 months. Twenty of 24 patients were on additional sildenafil and/or prostacyclins. Two of 24 patients discontinued because of peripheral edema. Within the entire cohort, BNP levels and all echo measures such as right ventricular systolic pressure (RVSP), right ventricular end-diastolic diameter (RVED), tricuspid annular plane systolic excursion (TAPSE), pulmonary velocity time integral (VTI), and pulmonary artery acceleration time (PAAT) improved significantly after 3 months (p ≤ 0.01), whereas in the long term significant improvement persisted for BNP levels (-16%), VTI (+14%) and PAAT (+11%) (p < 0.05). By subgroup analysis, non-CHD PH patients showed significant improvements in BNP levels (-57%) and all echo measures (TAPSE +21%, VTI +13%, PAAT +37%, RVSP -24%, RVED -12%) at 3 months (p ≤ 0.01), whereas at 12 months, improvements persisted (p < 0.05) except for RVSP and RVED (nonsignificant). In CHD-PH patients, none of the measures changed (nonsignificant). 6-MWD (distance walked in 6 minutes) slightly increased but was not statistically evaluated. CONCLUSION Data presented herein account for the largest cohort of severely affected pediatric patients receiving macitentan. Overall, macitentan was safe and associated with significant beneficial effects and sustained positive signals after 1 year, albeit in the long term disease progression remains a major concern. Our data suggest limited efficacy in CHD-related PH, whereas favorable outcomes were mainly driven by improvements in patients with PH not related to CHD. Larger studies are needed to verify these preliminary results and to prove efficacy of this drug in different pediatric PH entities.
Collapse
Affiliation(s)
- Sulaima Albinni
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Cardiology, Pediatric Heart Center Vienna, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Julian Heno
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Cardiology, Pediatric Heart Center Vienna, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Imre Pavo
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Cardiology, Pediatric Heart Center Vienna, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Erwin Kitzmueller
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Cardiology, Pediatric Heart Center Vienna, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Manfred Marx
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Cardiology, Pediatric Heart Center Vienna, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ina Michel-Behnke
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Cardiology, Pediatric Heart Center Vienna, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| |
Collapse
|
5
|
DesJardin JT, Svetlichnaya Y, Kolaitis NA, Hays SR, Kukreja J, Schiller NB, Zier LS, Singer JP, De Marco T. Echocardiographic estimation of pulmonary vascular resistance in advanced lung disease. Pulm Circ 2023; 13:e12183. [PMID: 36618711 PMCID: PMC9817072 DOI: 10.1002/pul2.12183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/22/2022] [Accepted: 12/13/2022] [Indexed: 12/31/2022] Open
Abstract
Noninvasive assessment of pulmonary hemodynamics is often performed by echocardiographic estimation of the pulmonary artery systolic pressure (ePASP), despite limitations in the advanced lung disease population. Other noninvasive hemodynamic variables, such as echocardiographic pulmonary vascular resistance (ePVR), have not been studied in this population. We performed a retrospective analysis of 147 advanced lung disease patients who received both echocardiography and right heart catheterization for lung transplant evaluation. The ePVR was estimated by four previously described equations. Noninvasive and invasive hemodynamic parameters were compared in terms of correlation, agreement, and accuracy. The ePVR models strongly correlated with invasively determined PVR and had good accuracy with biases of <1 Wood units (WU), although with moderate precision and wide 95% limits of agreement varying from 5.9 to 7.8 Wood units. The ePVR models were accurate to within 1.9 WU in over 75% of patients. In comparison to the ePASP, ePVR models performed similarly in terms of correlation, accuracy, and precision when estimating invasive hemodynamics. In screening for pulmonary hypertension, ePVR models had equivalent testing characteristics to the ePASP. Mid-systolic notching of the right ventricular outflow tract Doppler signal identified a subgroup of 11 patients (7%) with significantly elevated PVR and mean pulmonary artery pressures without relying on the acquisition of a tricuspid regurgitation signal. Analysis of ePVR and determination of the notching pattern of the right ventricular outflow tract Doppler flow velocity envelope provide reliable insights into hemodynamics in advanced lung disease patients, although limitations in precision exist.
Collapse
Affiliation(s)
| | | | - Nicholas A. Kolaitis
- Division of Pulmonary, Critical Care, Allergy, and Sleep MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Steven R. Hays
- Division of Pulmonary, Critical Care, Allergy, and Sleep MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Jasleen Kukreja
- Division of Adult Cardiothoracic SurgeryUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Nelson B. Schiller
- Division of CardiologyUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Lucas S. Zier
- Division of CardiologyUniversity of California San FranciscoSan FranciscoCaliforniaUSA,Division of CardiologyZuckerberg San Francisco General Hospital and Trauma CenterSan FranciscoCaliforniaUSA
| | - Jonathan P. Singer
- Division of Pulmonary, Critical Care, Allergy, and Sleep MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Teresa De Marco
- Division of CardiologyUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| |
Collapse
|
6
|
Lachance L, Conversy B, Wiggen K, Pavard C, Reinero C, Masseau I. No evidence of pulmonary hypertension revealed in an echographic evaluation of right-sided hemodynamics in hyperthyroid cats. J Feline Med Surg 2022; 24:e558-e567. [PMID: 36350661 PMCID: PMC9742920 DOI: 10.1177/1098612x221127102] [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] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Hyperthyroidism is a common endocrinopathy affecting middle-aged to elderly cats, with multisystemic repercussions. Hyperthyroid humans show decreased lung compliance and increased cardiac output with subsequent left heart failure leading to pulmonary capillary congestion. Prognosis worsens with the development of increased pulmonary vascular pressures (ie, pulmonary hypertension [PH]) in hyperthyroid humans. The effect of excess thyroid hormone concentration on pulmonary arterial hemodynamics is unknown in cats. Assessing pulmonary vascular pressures in veterinary medicine relies heavily on echocardiographic measurements performed at the level of the heart and pulmonary trunk. This study investigated right-sided cardiac and pulmonary arterial hemodynamics in hyperthyroid cats using echocardiography. METHODS Echocardiographic examinations of hyperthyroid cats identified through a bi-institutional database search were reviewed for the determination of systolic pulmonary arterial pressure (PAP) and 20 other metrics. Values were compared with those of a healthy cat group using non-parametric statistical analyses. RESULTS Systolic PAP could not be determined in 23/26 hyperthyroid and 13/14 healthy cats owing to unmeasurable tricuspid regurgitation flow velocity. Hyperthyroid cats were roughly twice as old (P <0.001) and had 2-4-fold higher respiratory rates (P <0.001) than healthy cats. Hyperthyroid cats showed an increase in acceleration time-to-ejection time ratio of pulmonary flow (1.4-fold, P = 0.001), pulmonary artery velocity time integral (1.2-1.6-fold, P = 0.001), maximal pulmonary velocity (1.3-1.7-fold, P = 0.002), stroke volume (1.5-fold, P = 0.001) and cardiac output (1.6-fold, P <0.001) vs healthy cats. None of the other echocardiographic metrics reached statistical significance. CONCLUSIONS AND RELEVANCE Systolic PAP estimation proved unsuitable as a sole measurement for the assessment of PH in hyperthyroid cats owing to the frequent inability to interrogate tricuspid regurgitant flow velocity. Hyperthyroid cats have altered echocardiographic measures of pulmonary hemodynamics dissimilar to those reported in hyperthyroid humans. Differential effects of thyrotoxic cardiomyopathy on ventricular systolic function may underlie species differences.
Collapse
Affiliation(s)
- Laury Lachance
- Department of Clinical Sciences,
Faculty of Veterinary Medicine, University of Montréal, Saint-Hyacinthe,
Canada
| | - Bérénice Conversy
- Department of Clinical Sciences,
Faculty of Veterinary Medicine, University of Montréal, Saint-Hyacinthe,
Canada
| | - Kelly Wiggen
- Department of Veterinary Medicine and
Surgery, University of Missouri Veterinary Health Center, College of Veterinary
Medicine, University of Missouri, Columbia, MO, USA
| | - Christophe Pavard
- Department of Clinical Sciences,
Faculty of Veterinary Medicine, University of Montréal, Saint-Hyacinthe,
Canada
| | - Carol Reinero
- Department of Veterinary Medicine and
Surgery, University of Missouri Veterinary Health Center, College of Veterinary
Medicine, University of Missouri, Columbia, MO, USA
| | - Isabelle Masseau
- Department of Clinical Sciences,
Faculty of Veterinary Medicine, University of Montréal, Saint-Hyacinthe,
Canada,Isabelle Masseau DVM, PhD, Dipl ACVR,
Department of Clinical Sciences, Faculty of Veterinary Medicine, University of
Montréal, 3200 Sicotte, Saint-Hyacinthe, QC J2S 2M2, Canada
| |
Collapse
|
7
|
Zi-Yang Y, Hezhi L, Nanshan X, Yin Z, Dongling L, Hongwen F, Caojin Z. Model for screening adult congenital heart disease surgery eligibility with echocardiography parameters. J Heart Lung Transplant 2022; 41:1831-1838. [PMID: 36150995 DOI: 10.1016/j.healun.2022.08.016] [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: 02/07/2022] [Revised: 07/30/2022] [Accepted: 08/22/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES This study aimed to screen for the eligibility of correction in cases of adult congenital heart disease (CHD). Pulmonary to systemic flow ratios (Qp/Qs) > 1.5 and pulmonary to systemic vascular resistance ratios (Rp/Rs) < 1/3, acquired by right heart catheterization (RHC), are two essential parameters. Nonetheless, performing RHC at every follow-up is impractical and even harmful. Thus, it is important to establish a model to predict Qp/Qs and Rp/Rs status before a RHC confirmation, using echocardiography parameters. METHODS A total of 1,785 patients with adult CHD were enrolled and randomly assigned to the derivation or validation groups. Echocardiogram parameters of the 974 patients in the derivation group were considered candidate predictors for surgery eligibility (Qp/Qs > 1.5 and Rp/Rs < 1/3). Binary logistic regression analyses were performed to identify the independent predictors and establish a scoring system. The scoring system was further examined in the validation group using a receiver operating characteristic (ROC) analysis. RESULTS Estimated pulmonary artery systolic pressure, velocity through the pulmonary valve, and diameters of the left and right atria were identified as independent predictors. The area under the ROC curve of the predictive value in the validation group and its pre- and post-tricuspid valve malformation subgroups were 0.87 (95% confidence interval [CI]: 0.84-0.90, p < 0.01), 0.86 (95% CI: 0.82-0.91, p < 0.01), and 0.85 (95% CI: 0.79-0.90, p < 0.01), respectively. CONCLUSIONS This scoring system could augment flexibility and convenience for pre-screening CHD patients' eligibility for surgery, before RHC.
Collapse
Affiliation(s)
- Yang Zi-Yang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Southern Medical University, The Second School of Clinical Medicine, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China
| | - Li Hezhi
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Xie Nanshan
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Southern Medical University, The Second School of Clinical Medicine, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China
| | - Zhou Yin
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China
| | - Luo Dongling
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Fei Hongwen
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Southern Medical University, The Second School of Clinical Medicine, Guangzhou, Guangdong, China.
| | - Zhang Caojin
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China; Southern Medical University, The Second School of Clinical Medicine, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, Guangdong, China.
| |
Collapse
|
8
|
Parikh RR, Norby FL, Wang W, Thenappan T, Prins KW, Van't Hof JR, Lutsey PL, Solomon SD, Shah AM, Chen LY. Association of Right Ventricular Afterload With Atrial Fibrillation Risk in Older Adults: The Atherosclerosis Risk in Communities Study. Chest 2022; 162:884-893. [PMID: 35562059 PMCID: PMC9659616 DOI: 10.1016/j.chest.2022.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is widely perceived to originate from the left atrium (LA). Whether increases in right ventricular (RV) afterload in older adults play an etiological role in AF genesis independent of LA and left ventricular (LV) remodeling is unknown. RESEARCH QUESTION Is higher RV afterload associated with greater AF risk independent of LA and LV remodeling? STUDY DESIGN AND METHODS In this observational prospective study, we included 2,246 community-dwelling older adults (mean age, 75 years) without known cardiovascular disease, with LV ejection fraction > 50%, LA volume index < 34 mL/m2, and E/e' ratio < 14 and a measurable functional tricuspid regurgitation jet velocity. From 2D-echocardiograms, we estimated pulmonary artery systolic pressure (PASP) and pulmonary vascular resistance (PVR). We ascertained incident AF (through 2018) from hospital discharge codes and death certificates. We estimated hazard ratios (HR) by Cox regression. RESULTS During follow-up (median, 6.3 years; interquartile interval, 5.5-6.9 years), 215 participants developed AF. AF risk was significantly higher in the third (vs first) tertile of PASP (HR, 1.65; 95% CI, 1.08-2.54) and PVR (HR, 1.38; 95% CI, 1.00-2.08) independent of LA and LV structure and function, heart rate, BMI, prevalent sleep apnea, systemic BP, antihypertensive medications, and lung, kidney, and thyroid function. These associations persisted after further exclusion of participants with tricuspid regurgitation jet velocity > 2.8 m/s and lateral and septal mitral annular velocity above age- and sex-specific reference limits. INTERPRETATION In older adults, higher RV afterload is associated with greater AF risk independent of LA and LV remodeling. Future research should focus on confirming this novel association and elucidate underlying mechanisms.
Collapse
Affiliation(s)
- Romil R Parikh
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN; Lillehei Heart Institute and Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Faye L Norby
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN; Center for Cardiac Arrest Prevention, Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
| | - Wendy Wang
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN; Lillehei Heart Institute and Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Thenappan Thenappan
- Lillehei Heart Institute and Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Kurt W Prins
- Lillehei Heart Institute and Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Jeremy R Van't Hof
- Lillehei Heart Institute and Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Amil M Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Lin Yee Chen
- Lillehei Heart Institute and Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN.
| |
Collapse
|
9
|
McGlothlin D, Granton J, Klepetko W, Beghetti M, Rosenzweig EB, Corris P, Horn E, Kanwar M, McRae K, Roman A, Tedford R, Badagliacca R, Bartolome S, Benza R, Caccamo M, Cogswell R, Dewachter C, Donahoe L, Fadel E, Farber HW, Feinstein J, Franco V, Frantz R, Gatzoulis M, Hwa (Anne) Goh C, Guazzi M, Hansmann G, Hastings S, Heerdt P, Hemnes A, Herpain A, Hsu CH, Kerr K, Kolaitis N, Kukreja J, Madani M, McCluskey S, McCulloch M, Moser B, Navaratnam M, Radegran G, Reimer C, Savale L, Shlobin O, Svetlichnaya J, Swetz K, Tashjian J, Thenappan T, Vizza CD, West S, Zuckerman W, Zuckermann A, De Marco T. ISHLT CONSENSUS STATEMENT: Peri-operative Management of Patients with Pulmonary Hypertension and Right Heart Failure Undergoing Surgery. J Heart Lung Transplant 2022; 41:1135-1194. [DOI: 10.1016/j.healun.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 10/17/2022] Open
|
10
|
Edmonston DL, Matsouaka R, Shah SH, Rajagopal S, Wolf M. Noninvasive Risk Score to Screen for Pulmonary Hypertension With Elevated Pulmonary Vascular Resistance in Diseases of Chronic Volume Overload. Am J Cardiol 2021; 159:113-120. [PMID: 34497006 PMCID: PMC10153469 DOI: 10.1016/j.amjcard.2021.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/03/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
Volume overload promotes pulmonary hypertension (PH) through pulmonary venous hypertension. However, PH with elevated pulmonary vascular resistance (hereafter PH-PVR) may develop in patients with diseases of volume overload, such as heart failure or chronic kidney disease (CKD). In such cases, volume management alone may be insufficient to slow PH progression. An accurate, noninvasive method to screen for PH-PVR in these diseases would facilitate early targeted therapy. We integrated invasive hemodynamic and echocardiography data collected from a single-center clinical cohort and identified patients with CKD or heart failure at the time of assessment. We applied penalized regression to derive a risk score of clinical parameters and echocardiography data associated with PH-PVR and categorized patients into low- (≤5 points), intermediate- (6-10 points), or high-risk (>10 points) groups. Using an internal validation strategy, we evaluated the ability of this risk score to predict PH-PVR and determined the association of this risk classification with 3-year all-cause mortality. Of 2422 patients, 42.4% had PH-PVR. In adjusted analyses, tricuspid regurgitant velocity, right ventricular function, BMI, heart rate, and hemoglobin most strongly associated with PH-PVR. The risk score significantly associated with PH-PVR (age-adjusted odds ratio 11.69 for the highest-risk group, 95% confidence interval [CI] 6.54-20.92). The high-risk group also associated with a significantly higher risk of 3-year all-cause mortality in adjusted analyses (hazard ratio 1.85, 95% CI 1.50-2.27). In conclusion, a noninvasive risk score derived from echocardiography and clinical parameters significantly associated with PH-PVR and all-cause mortality in a cohort of patients with CKD and heart failure.
Collapse
|
11
|
Suzuki R, Yuchi Y, Kanno H, Saito T, Teshima T, Matsumoto H, Koyama H. Pulmonary Vascular Resistance Estimated by Echocardiography in Dogs With Myxomatous Mitral Valve Disease and Pulmonary Hypertension Probability. Front Vet Sci 2021; 8:771726. [PMID: 34765671 PMCID: PMC8576378 DOI: 10.3389/fvets.2021.771726] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/29/2021] [Indexed: 11/29/2022] Open
Abstract
Post-capillary pulmonary hypertension (PH) is a life-threatening complication in dogs with myxomatous mitral valve disease (MMVD). An increase in pulmonary vascular resistance (PVR) is associated with post-capillary PH progression. In humans, PVR estimated by echocardiography (PVRecho) enables the non-invasive assessment of PVR in patients with PH. This study aimed to evaluate the clinical utility of PVRecho in dogs with MMVD, PH probability, and right-sided congestive heart failure (R-CHF). Dogs with MMVD and detectable tricuspid valve regurgitation were included in the study. Dogs were classified into three PH probability groups (low/intermediate/high) and according to the presence or absence of R-CHF. All dogs underwent echocardiographic measurements for right ventricular (RV) morphology and function. PVRecho was calculated by two methods using tricuspid valve regurgitation velocity and velocity–time integral of the pulmonary artery flow (PVRecho and PVRecho2). RV size indicators were significantly higher with a higher probability of PH. RV strain and velocity–time integral of the pulmonary artery flow in the high probability group were significantly lower than those in the other groups. Tricuspid valve regurgitation velocity, PVRecho, and PVRecho2 were significantly higher with an increase in PH probability. Logistic regression analysis revealed a significant association between the presence of R-CHF and increased PVRecho2 and end-diastolic RV internal dimension normalized by body weight. PVRecho and PVRecho2 showed significant differences among the PH probability groups. These non-invasive variables may be useful for the diagnosis and stratification of PH and the determination of the presence of R-CHF in dogs with MMVD.
Collapse
Affiliation(s)
- Ryohei Suzuki
- Laboratory of Veterinary Internal Medicine, Faculty of Veterinary Medicine, School of Veterinary Science, Nippon Veterinary and Life Science University, Musashino, Japan
| | - Yunosuke Yuchi
- Laboratory of Veterinary Internal Medicine, Faculty of Veterinary Medicine, School of Veterinary Science, Nippon Veterinary and Life Science University, Musashino, Japan
| | - Haruka Kanno
- Laboratory of Veterinary Internal Medicine, Faculty of Veterinary Medicine, School of Veterinary Science, Nippon Veterinary and Life Science University, Musashino, Japan
| | - Takahiro Saito
- Laboratory of Veterinary Internal Medicine, Faculty of Veterinary Medicine, School of Veterinary Science, Nippon Veterinary and Life Science University, Musashino, Japan
| | - Takahiro Teshima
- Laboratory of Veterinary Internal Medicine, Faculty of Veterinary Medicine, School of Veterinary Science, Nippon Veterinary and Life Science University, Musashino, Japan
| | - Hirotaka Matsumoto
- Laboratory of Veterinary Internal Medicine, Faculty of Veterinary Medicine, School of Veterinary Science, Nippon Veterinary and Life Science University, Musashino, Japan
| | - Hidekazu Koyama
- Laboratory of Veterinary Internal Medicine, Faculty of Veterinary Medicine, School of Veterinary Science, Nippon Veterinary and Life Science University, Musashino, Japan
| |
Collapse
|
12
|
Fontes Oliveira M, Oliveira MI, Furtado I, Carvalho L, Gonçalves F, Reis A, Santos M. External validation of different clinical and echocardiographic scores to distinguish post- from precapillary pulmonary hypertension. Echocardiography 2021; 38:1558-1566. [PMID: 34355812 DOI: 10.1111/echo.15172] [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: 02/07/2021] [Revised: 07/11/2021] [Accepted: 07/23/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Even though right heart catheterization (RHC) is the gold-standard method to characterise Pulmonary Hypertension (PH), it cannot be performed in all the patients with suspected PH. Clinical and echocardiographic scores have been developed to differentiate PH secondary to heart failure with preserved ejection fraction (PH-HFpEF) from pre-capillary PH. We aimed to compare the performance of non-invasive parameters in a population with suspected PH. METHODS We retrospectively included consecutive patients who underwent RHC for suspected PH. Patients with a non-invasive evaluation clearly suggestive of left heart disease were excluded. We assessed the performance of non-invasive pulmonary vascular resistance (PVR), echocardiographic pulmonary to left atrial ratio (ePLAR), and Opotowsky, Richter, Berthelot, and D'Alto scores using the area under curve (AUC) of the receiver operating characteristic curves. RESULTS Of the 142 included patients, 61 patients had pre-capillary PH, 49 had PH-HFpEF, and 32 patients did not meet invasive criteria for PH. We were able to perform the aforementioned scores in 71-100% of our patients. Using the original cut-offs, Opotowsky was the score that best predicted precapillary PH (96% sensitivity, 41% specificity, AUC .69), followed by D'Alto (98% sensitivity, 22% specificity, AUC .60) and Berthelot (32% sensitivity, 90% specificity, AUC .60). Richter score did not discriminate between phenotypes (AUC .50). Using optimised cut-offs, a Berthelot score < 9 predicted precapillary PH with 73% sensitivity and 74% specificity (AUC .73). Single echocardiographic parameters as non-invasive PVR (85% sensitivity, 59% specificity, AUC .72) and ePLAR (73% sensitivity, 76% specificity, AUC .75) showed better prediction performance than the composite studied scores. CONCLUSION Combined clinical and echocardiographic characteristics can be used to predict pre-capillary PH with moderate performance. The application of these non-invasive parameters in clinical practice can help refine referral to RHC in a population with clinically suspected PH.
Collapse
Affiliation(s)
- Marta Fontes Oliveira
- Cardiology Department, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
| | - Maria Isilda Oliveira
- Centre of Physical Activity, Health and Leisure, Faculdade de Desporto da Universidade do Porto, R. Dr. Plácido da Costa 91, Porto, Portugal
| | - Inês Furtado
- Pulmonary Vascular Disease Unit, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
| | - Luísa Carvalho
- Pulmonary Vascular Disease Unit, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
| | - Fabienne Gonçalves
- Pulmonary Vascular Disease Unit, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
| | - Abílio Reis
- Pulmonary Vascular Disease Unit, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
| | - Mário Santos
- Cardiology Department, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal.,Pulmonary Vascular Disease Unit, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
| |
Collapse
|
13
|
Bleakley C, de Marvao A, Morosin M, Androulakis E, Russell C, Athayde A, Cannata A, Passariello M, Ledot S, Singh S, Pepper J, Hill J, Cowie M, Price S. Utility of echocardiographic right ventricular subcostal strain in critical care. Eur Heart J Cardiovasc Imaging 2021; 23:820-828. [PMID: 34160032 DOI: 10.1093/ehjci/jeab105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/12/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS Right ventricular (RV) strain is a known predictor of outcomes in various heart and lung pathologies but has been considered too technically challenging for routine use in critical care. We examined whether RV strain acquired from the subcostal view, frequently more accessible in the critically ill, is an alternative to conventionally derived RV strain in intensive care. METHODS AND RESULTS RV strain data were acquired from apical and subcostal views on transthoracic echocardiography (TTE) in 94 patients (35% female), mean age 50.5 ± 15.2 years, venovenous extracorporeal membrane oxygenation (VVECMO) (44%). RV strain values from the apical (mean ± standard deviation; -20.4 ± 6.7) and subcostal views (-21.1 ± 7) were highly correlated (Pearson's r -0.89, P < 0.001). RV subcostal strain correlated moderately well with other echocardiography parameters including tricuspid annular plane systolic excursion (r -0.44, P < 0.001), RV systolic velocity (rho = -0.51, P < 0.001), fractional area change (r -0.66, P < 0.01), and RV outflow tract velocity time integral (r -0.49, P < 0.001). VVECMO was associated with higher RV subcostal strain (non-VVECMO -19.6 ± 6.7 vs. VVECMO -23.2 ± 7, P = 0.01) but not apical RV strain. On univariate analysis, RV subcostal strain was weakly associated with survival at 30 days (R2 = 0.04, P = 0.05, odds ratio =1.08) while apical RV was not (P = 0.16). CONCLUSION RV subcostal deformation imaging is a reliable surrogate for conventionally derived strain in critical care and may in time prove to be a useful diagnostic marker in this cohort.
Collapse
Affiliation(s)
- Caroline Bleakley
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.,Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - Antonio de Marvao
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.,MRC London Institute of Medical Sciences, Imperial College London, London, UK
| | - Marco Morosin
- Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - Emmanouil Androulakis
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Clare Russell
- Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - Andre Athayde
- Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - Antonio Cannata
- Department of Cardiology, King's College Hospital, London, UK
| | - Maurizio Passariello
- Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - Stéphane Ledot
- Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - Suveer Singh
- Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - John Pepper
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Jonathan Hill
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Martin Cowie
- Royal Brompton Hospital & School of Cardiovascular Medicine & Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Susanna Price
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.,Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| |
Collapse
|
14
|
Hockstein MA, Haycock K, Wiepking M, Lentz S, Dugar S, Siuba M. Transthoracic Right Heart Echocardiography for the Intensivist. J Intensive Care Med 2021; 36:1098-1109. [PMID: 33853435 DOI: 10.1177/08850666211003475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The impact of critical illness on the right ventricle (RV) can be profound and RV dysfunction is associated with mortality. Intensivists are becoming more facile with bedside echocardiography, however, pedagogy has largely focused on left ventricular function. Here we review measurements of right heart function by way of echocardiographic modalities and list clinical scenarios where the RV dysfunction is a salient feature. MAIN RV dysfunction is heterogeneously defined across many domains and its diagnosis is not always clinically apparent. The RV is affected by conditions commonly seen in the ICU such as acute respiratory distress syndrome, pulmonary embolism, RV ischemia, and pulmonary hypertension. Basic ultrasonographic modalities such as 2D imaging, M-mode, tissue Doppler, pulsed-wave Doppler, and continuous Doppler provide clinicians with metrics to assess RV function and response to therapy. CONCLUSION The right ventricle is impacted by various critical illnesses with substantial mortality and mortality. Focused bedside echocardiographic exams with attention to the right heart may provide intensivists insight into RV function and provide guidance for patient management.
Collapse
Affiliation(s)
- Maxwell A Hockstein
- Departments of Emergency Medicine and Critical Care, 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Korbin Haycock
- Department of Emergency Medicine, 4608Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Matthew Wiepking
- Department of Emergency Medicine and Surgery, 12223University of Southern California-Keck School of Medicine, Los Angeles, CA, USA
| | - Skyler Lentz
- Division of Emergency Medicine and Pulmonary Disease & Critical Care Medicine, Department of Surgery and Medicine, Larner College of 12352Medicine-University of Vermont, Burlington, VT, USA
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Siuba
- Department of Critical Care Medicine, Respiratory Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
15
|
Bleakley C, Singh S, Garfield B, Morosin M, Surkova E, Mandalia MS, Dias B, Androulakis E, Price LC, McCabe C, Wort SJ, West C, Li W, Khattar R, Senior R, Patel BV, Price S. Right ventricular dysfunction in critically ill COVID-19 ARDS. Int J Cardiol 2020; 327:251-258. [PMID: 33242508 PMCID: PMC7681038 DOI: 10.1016/j.ijcard.2020.11.043] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/09/2020] [Accepted: 11/18/2020] [Indexed: 02/06/2023]
Abstract
Aims Comprehensive echocardiography assessment of right ventricular (RV) impairment has not been reported in critically ill patients with COVID-19. We detail the specific phenotype and clinical associations of RV impairment in COVID-19 acute respiratory distress syndrome (ARDS). Methods Transthoracic echocardiography (TTE) measures of RV function were collected in critically unwell patients for associations with clinical, ventilatory and laboratory data. Results Ninety patients (25.6% female), mean age 52.0 ± 10.8 years, veno-venous extracorporeal membrane oxygenation (VVECMO) (42.2%) were studied. A significantly higher proportion of patients were identified as having RV dysfunction by RV fractional area change (FAC) (72.0%,95% confidence interval (CI) 61.0–81.0) and RV velocity time integral (VTI) (86.4%, 95 CI 77.3–93.2) than by tricuspid annular plane systolic excursion (TAPSE) (23.8%, 95 CI 16.0–33.9), RVS’ (11.9%, 95% CI 6.6–20.5) or RV free wall strain (FWS) (35.3%, 95% CI 23.6–49.0). RV VTI correlated strongly with RV FAC (p ≤ 0.01). Multivariate regression demonstrated independent associations of RV FAC with NTpro-BNP and PVR. RV-PA coupling correlated with PVR (univariate p < 0.01), as well as RVEDAi (p < 0.01), and RVESAi (p < 0.01), and was associated with P/F ratio (p 0.026), PEEP (p 0.025), and ALT (p 0.028). Conclusions Severe COVID-19 ARDS is associated with a specific phenotype of RV radial impairment with sparing of longitudinal function. Clinicians should avoid interpretation of RV health purely on long-axis parameters in these patients. RV-PA coupling potentially provides important additional information above standard measures of RV performance in this cohort.
Collapse
Affiliation(s)
- Caroline Bleakley
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, UK; Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - Suveer Singh
- Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - Benjamin Garfield
- Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - Marco Morosin
- Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - Elena Surkova
- Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London, UK
| | | | - Bernardo Dias
- Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London, UK
| | | | - Laura C Price
- Pulmonary Hypertension Service, Royal Brompton Hospital, Sydney Street, London, UK
| | - Colm McCabe
- Pulmonary Hypertension Service, Royal Brompton Hospital, Sydney Street, London, UK
| | - Stephen John Wort
- Pulmonary Hypertension Service, Royal Brompton Hospital, Sydney Street, London, UK
| | - Cathy West
- Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London, UK
| | - Wei Li
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, UK; Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London, UK
| | - Rajdeep Khattar
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, UK; Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London, UK
| | - Roxy Senior
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, UK; Department of Echocardiography, Royal Brompton Hospital, Sydney Street, London, UK
| | - Brijesh V Patel
- Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK
| | - Susanna Price
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, UK; Department of Adult Critical Care, Royal Brompton Hospital, Sydney Street, London, UK.
| |
Collapse
|
16
|
Vaidya A, Golbus JR, Vedage NA, Mazurek J, Raza F, Forfia PR. Virtual echocardiography screening tool to differentiate hemodynamic profiles in pulmonary hypertension. Pulm Circ 2020; 10:2045894020950225. [PMID: 32994924 PMCID: PMC7504864 DOI: 10.1177/2045894020950225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/21/2020] [Indexed: 01/08/2023] Open
Abstract
This study validated a novel virtual echocardiography screening tool (VEST), which utilized routinely reported echocardiography parameters to predict hemodynamic profiles in pulmonary hypertension (PH) and identify PH due to pulmonary vascular disease (PHPVD). Direct echocardiography imaging review has been shown to predict hemodynamic profiles in PH; however, routine use often overemphasizes Doppler-estimated pulmonary artery systolic pressure (PASPDE), which lacks discriminatory power among hemodynamically varied PH subgroups. In patients with PH of varying subtypes at a tertiary referral center, reported echocardiographic findings needed for VEST, including left atrial size, E:e' and systolic interventricular septal flattening, were obtained. Receiver operating characteristic analyses assessed the predictive performance of VEST vs. PASPDE in identifying PHPVD, which was later confirmed by right heart catheterization. VEST demonstrated far superior discriminatory power than PASPDE in identifying PHPVD. A positive score was 80.0% sensitive and 75.6% specific for PHPVD with an area under the curve of 0.81. PASPDE exhibited poorer discriminatory power with an area under the curve of 0.56. VEST's strong discriminatory ability remained unchanged when validated in a second cohort from another tertiary center. We demonstrated that this novel VEST using three routine parameters that can be easily extracted from standard echocardiographic reports can successfully capture PH patients with a high likelihood of PHPVD. During the Covid-19 pandemic, when right heart catheterization and timely access to experts at accredited PH centers may have limited widespread availability, this may assist physicians to rapidly and remotely evaluate PH patients to ensure timely and appropriate care.
Collapse
Affiliation(s)
- Anjali Vaidya
- Department of Medicine, Cardiovascular
Division, Pulmonary Hypertension, Right Heart Failure and CTEPH Program, Temple
University School of Medicine, Philadelphia, PA, USA
| | - Jessica R. Golbus
- Department of Medicine, Cardiovascular
Division, University of Michigan, Ann Arbor, MI, USA
| | - Natasha A. Vedage
- Department of Medicine, Cardiovascular
Division, Pulmonary Hypertension, Right Heart Failure and CTEPH Program, Temple
University School of Medicine, Philadelphia, PA, USA
| | - Jeremy Mazurek
- Department of Medicine, Cardiovascular
Division, Heart Failure and Pulmonary Hypertension Program, Hospital of the
University of Pennsylvania, Philadelphia, PA, USA
| | - Farhan Raza
- Department of Medicine, Cardiovascular
Division, University of Wisconsin, Madison, WI, USA
| | - Paul R. Forfia
- Department of Medicine, Cardiovascular
Division, Pulmonary Hypertension, Right Heart Failure and CTEPH Program, Temple
University School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
17
|
Rao SD, Adusumalli S, Mazurek JA. Pulmonary Hypertension in Heart Failure Patients. Card Fail Rev 2020; 6:e05. [PMID: 32377384 PMCID: PMC7199161 DOI: 10.15420/cfr.2019.09] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 12/13/2019] [Indexed: 12/29/2022] Open
Abstract
The development of pulmonary hypertension (PH) in patients with heart failure is associated with increased morbidity and mortality. In this article, the authors examine recent changes to the definition of PH in the setting of left heart disease (PH-LHD), and discuss its epidemiology, pathophysiology and prognosis. They also explore the complexities of diagnosing PH-LHD and the current evidence for the use of medical therapies, promising clinical trials and the role of left ventricular assist device and transplantation.
Collapse
Affiliation(s)
- Sriram D Rao
- Advanced Heart Failure/Transplantation Programme, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania Philadelphia, PA, US
| | - Srinath Adusumalli
- Department of Medicine, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania Philadelphia, PA, US
| | - Jeremy A Mazurek
- Advanced Heart Failure/Transplantation Programme, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania Philadelphia, PA, US.,Pulmonary Hypertension Programme, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania Philadelphia, PA, US
| |
Collapse
|
18
|
Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM, Crumb SR, Dearani JA, Fuller S, Gurvitz M, Khairy P, Landzberg MJ, Saidi A, Valente AM, Van Hare GF. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2020; 139:e698-e800. [PMID: 30586767 DOI: 10.1161/cir.0000000000000603] [Citation(s) in RCA: 233] [Impact Index Per Article: 58.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Karen K Stout
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Curt J Daniels
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Jamil A Aboulhosn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Biykem Bozkurt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Craig S Broberg
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Jack M Colman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Stephen R Crumb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Joseph A Dearani
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Stephanie Fuller
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Michelle Gurvitz
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Paul Khairy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Michael J Landzberg
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Arwa Saidi
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Anne Marie Valente
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - George F Van Hare
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| |
Collapse
|
19
|
Agrawal V, D'Alto M, Naeije R, Romeo E, Xu M, Assad TR, Robbins IM, Newman JH, Pugh ME, Hemnes AR, Brittain EL. Echocardiographic Detection of Occult Diastolic Dysfunction in Pulmonary Hypertension After Fluid Challenge. J Am Heart Assoc 2019; 8:e012504. [PMID: 31475602 PMCID: PMC6755835 DOI: 10.1161/jaha.119.012504] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Identification of occult diastolic dysfunction often requires invasive right heart catheterization with provocative maneuvers such as fluid challenge. Non-invasive predictors of occult diastolic dysfunction have not been identified. We hypothesized that echocardiographic measures of diastolic function are associated with occult diastolic dysfunction identified at catheterization. Methods and Results We retrospectively examined hemodynamic and echocardiographic data from consecutive patients referred for right heart catheterization with fluid challenge from 2009 to 2017. A replication cohort of 52 patients who prospectively underwent simultaneous echocardiography and right heart catheterization before and after fluid challenge at Monaldi Hospital, Naples, Italy. In the retrospective cohort of 126 patients (83% female, 56+14 years), 27/126 (21%) had occult diastolic dysfunction. After adjusting for tricuspid regurgitant velocity and left atrial volume index, E velocity (odds ratio 1.8, 95% CI 1.1-2.9, P=0.01) and E/e' (odds ratio 1.9, 95% CI 1.1-3, P=0.005) were associated with occult diastolic dysfunction with an optimal threshold of E/e' >8.6 for occult diastolic dysfunction (sensitivity 70%, specificity 64%). In the prospective cohort, 5/52 (10%) patients had diastolic dysfunction after fluid challenge. Resting E/e' (odds ratio 8.75, 95% CI 2.3-33, P=0.001) and E velocity (odds ratio 7.7, 95% CI 2-29, P=0.003) remained associated with occult diastolic dysfunction with optimal threshold of E/e' >8 (sensitivity 73%, specificity 90%). Conclusions Among patients referred for right heart catheterization with fluid challenge, E velocity and E/e' are associated with occult diastolic dysfunction after fluid challenge. These findings suggest that routine echocardiographic measurements may help identify patients like to have occult diastolic dysfunction non-invasively.
Collapse
Affiliation(s)
- Vineet Agrawal
- Division of Cardiology Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Michele D'Alto
- Department of Cardiology University "L. Vanvitelli" - Monaldi Hospital Naples Italy
| | - Robert Naeije
- Department of Cardiology Erasme University Hospital Brussels Belgium
| | - Emanuele Romeo
- Department of Cardiology University "L. Vanvitelli" - Monaldi Hospital Naples Italy
| | - Meng Xu
- Department of Biostatistics Vanderbilt University Nashville TN
| | - Tufik R Assad
- Division of Allergy, Pulmonology, and Critical Care Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Ivan M Robbins
- Division of Allergy, Pulmonology, and Critical Care Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - John H Newman
- Division of Allergy, Pulmonology, and Critical Care Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Meredith E Pugh
- Division of Allergy, Pulmonology, and Critical Care Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Anna R Hemnes
- Division of Allergy, Pulmonology, and Critical Care Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Evan L Brittain
- Division of Cardiology Department of Medicine Vanderbilt University Medical Center Nashville TN
| |
Collapse
|
20
|
Rao SD, Menachem JN, Birati EY, Mazurek JA. Pulmonary Hypertension in Advanced Heart Failure: Assessment and Management of the Failing RV and LV. Curr Heart Fail Rep 2019; 16:119-129. [DOI: 10.1007/s11897-019-00431-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
21
|
DesJardin JT, Manicardi M, Svetlichnaya Y, Kolaitis NA, Papolos AI, Selby VN, Zier LS, Klein L, Aras MA, Yao FY, Roberts JP, De Marco T. Noninvasive estimation of pulmonary vascular resistance improves portopulmonary hypertension screening in liver transplant candidates. Clin Transplant 2019; 33:e13585. [DOI: 10.1111/ctr.13585] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/22/2019] [Accepted: 05/04/2019] [Indexed: 01/28/2023]
Affiliation(s)
| | - Marcella Manicardi
- Department of Medicine University of California San Francisco San Francisco California
- Division of Cardiology University of California San Francisco San Francisco California
- Division of Cardiology University of Modena and Reggio Emilia Modena Italy
| | - Yana Svetlichnaya
- Department of Medicine University of California San Francisco San Francisco California
- Division of Cardiology University of California San Francisco San Francisco California
- Division of Cardiology Kaiser Permanente San Francisco California
| | - Nicholas A. Kolaitis
- Department of Medicine University of California San Francisco San Francisco California
- Division of Pulmonology University of California San Francisco San Francisco California
| | - Alexander I. Papolos
- Department of Medicine University of California San Francisco San Francisco California
- Division of Cardiology University of California San Francisco San Francisco California
| | - Van N. Selby
- Department of Medicine University of California San Francisco San Francisco California
- Division of Cardiology University of California San Francisco San Francisco California
| | - Lucas S. Zier
- Department of Medicine University of California San Francisco San Francisco California
- Division of Cardiology University of California San Francisco San Francisco California
- Division of Cardiology Zuckerberg San Francisco General Hospital and Trauma Center San Francisco California
| | - Liviu Klein
- Department of Medicine University of California San Francisco San Francisco California
- Division of Cardiology University of California San Francisco San Francisco California
| | - Mandar A. Aras
- Department of Medicine University of California San Francisco San Francisco California
- Division of Cardiology University of California San Francisco San Francisco California
| | - Francis Y. Yao
- Department of Medicine University of California San Francisco San Francisco California
- Division of Hepatology University of California San Francisco San Francisco California
| | - John P. Roberts
- Division of Transplant Surgery University of California San Francisco San Francisco California
| | - Teresa De Marco
- Department of Medicine University of California San Francisco San Francisco California
- Division of Cardiology University of California San Francisco San Francisco California
| |
Collapse
|
22
|
Bhattacharya PT, Troutman GS, Mao F, Fox AL, Tanna MS, Zamani P, Grandin EW, Menachem JN, Birati EY, Chirinos JA, Mazimba S, Smith KA, Kawut SM, Forfia PR, Vaidya A, Mazurek JA. Right ventricular outflow tract velocity time integral-to-pulmonary artery systolic pressure ratio: a non-invasive metric of pulmonary arterial compliance differs across the spectrum of pulmonary hypertension. Pulm Circ 2019; 9:2045894019841978. [PMID: 30880577 PMCID: PMC6540515 DOI: 10.1177/2045894019841978] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pulmonary arterial compliance (PAC), invasively assessed by the ratio of stroke
volume to pulmonary arterial (PA) pulse pressure, is a sensitive marker of right
ventricular (RV)-PA coupling that differs across the spectrum of pulmonary
hypertension (PH) and is predictive of outcomes. We assessed whether the
echocardiographically derived ratio of RV outflow tract velocity time integral
to PA systolic pressure (RVOT-VTI/PASP) (a) correlates with invasive PAC, (b)
discriminates heart failure with preserved ejection-associated PH (HFpEF-PH)
from pulmonary arterial hypertension (PAH), and (c) is associated with
functional capacity. We performed a retrospective cohort study of patients with
PAH (n = 70) and HFpEF-PH (n = 86), which was further dichotomized by diastolic
pressure gradient (DPG) into isolated post-capillary PH (DPG < 7 mmHg;
Ipc-PH, n = 54), and combined post- and pre-capillary PH (DPG ≥ 7 mm Hg; Cpc-PH,
n = 32). Of the 156 patients, 146 had measurable RVOT-VTI or PASP and were
included in further analysis. RVOT-VTI/PASP correlated with invasive PAC overall
(ρ = 0.61, P < 0.001) and for the PAH (ρ = 0.38,
P = 0.002) and HFpEF-PH (ρ = 0.63,
P < 0.001) groups individually. RVOT-VTI/PASP differed
significantly across the PH spectrum (PAH: 0.13 [0.010–0.25] vs. Cpc-PH: 0.20
[0.12–0.25] vs. Ipc-PH: 0.35 [0.22–0.44]; P < 0.001),
distinguished HFpEF-PH from PAH (AUC = 0.72, 95% CI = 0.63–0.81) and Cpc-PH from
Ipc-PH (AUC = 0.78, 95% CI = 0.68–0.88), and remained independently predictive
of 6-min walk distance after multivariate analysis (standardized
β-coefficient = 27.7, 95% CI = 9.2–46.3; P = 0.004).
Echocardiographic RVOT-VTI/PASP is a novel non-invasive metric of PAC that
differs across the spectrum of PH. It distinguishes the degree of pre-capillary
disease within HFpEF-PH and is predictive of functional capacity.
Collapse
Affiliation(s)
- Priyanka T. Bhattacharya
- Center for Clinical Epidemiology and
Biostatistics, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
- Department of Medicine, Perelman School
of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory S. Troutman
- Sidney Kimmel Medical College at Thomas
Jefferson University, Philadelphia, PA, USA
| | - Frances Mao
- Department of Medicine, Perelman School
of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Arieh L. Fox
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
| | - Monique S. Tanna
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
| | - Payman Zamani
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
| | - E. Wilson Grandin
- Division of Cardiology, Richard A. and
Susan F. Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess
Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jonathan N. Menachem
- Department of Medicine, Division of
Cardiovascular Medicine, Vanderbilt University, Nashville, TN, USA
| | - Edo Y. Birati
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
| | - Julio A. Chirinos
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
| | - Sula Mazimba
- University of Virginia Health System,
Charlottesville, VA, USA
| | - Kerri Akaya Smith
- Department of Medicine, Pulmonary
Hypertension Program, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
- Department of Medicine, Division of
Pulmonary, Allergy and Critical Care, Perelman School of Medicine at the University
of Pennsylvania, Philadelphia, PA, USA
| | - Steven M. Kawut
- Center for Clinical Epidemiology and
Biostatistics, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
- Department of Medicine, Pulmonary
Hypertension Program, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
- Department of Medicine, Division of
Pulmonary, Allergy and Critical Care, Perelman School of Medicine at the University
of Pennsylvania, Philadelphia, PA, USA
| | - Paul R. Forfia
- Pulmonary Hypertension, Right Heart
Failure and Pulmonary Thromboendarterectomy Program, Temple University Hospital,
Philadelphia, PA, USA
| | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart
Failure and Pulmonary Thromboendarterectomy Program, Temple University Hospital,
Philadelphia, PA, USA
| | - Jeremy A. Mazurek
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Pulmonary
Hypertension Program, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
- Jeremy A. Mazurek, Division of
Cardiovascular Medicine Hospital of the University of Pennsylvania, Perelman
Center for Advanced Medicine, South Pavilion, 11th Floor, Suite 11-179, 3400
Civic Center Boulevard, Philadelphia, PA 19104, USA.
| |
Collapse
|
23
|
Bai Y, Yang J, Liu J, Ning H, Zhang R. Right atrial function for the prediction of prognosis in connective tissue disease-associated pulmonary arterial hypertension: a study with two-dimensional speckle tracking. Int J Cardiovasc Imaging 2019; 35:1637-1649. [DOI: 10.1007/s10554-019-01613-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 04/25/2019] [Indexed: 12/18/2022]
|
24
|
Chen YJ, Ho CT, Tsai FC, Lin CP, Hsu LA, Wang CL, Lee KT, Ho WJ. Outcomes of Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension at a Single Center in Taiwan. ACTA CARDIOLOGICA SINICA 2019; 35:153-164. [PMID: 30930563 PMCID: PMC6434418 DOI: 10.6515/acs.201903_35(2).20180904a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 09/04/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is classified as group IV pulmonary hypertension. This study aimed to report our institutional experience in managing CTEPH. METHODS We prospectively collected the data of 23 patients diagnosed with CTEPH between August 2001 and August 2017 in Linkou Chang Gung Memorial Hospital. Baseline characteristics including functional class (FC), 6-minute walk distance (6MWD), comorbidities, hematological and biochemical data, echocardiography, cardiac catheterization, and selective pulmonary angiography were recorded at diagnosis. All patients were referred to a cardiac surgeon for pulmonary endarterectomy (PEA) assessment. RESULTS The mean age at diagnosis was 48.4 ± 16.1 years. Nineteen patients (83%) underwent PEA with mean postoperative follow-up of 37.7 ± 42.8 months. The in-hospital mortality rate of PEA was 11%. The 1-, 2-, 3- and 5-year overall survival rates were 89%, 89%, 81%, and 50%, respectively. After 3 months of PEA, all patients had improvements in FC, 6MWD (from 326 ± 62 to 420 ± 63 m), B-type natriuretic peptide level (from 602 ± 599 to 268 ± 565 pg/mL), and systolic pulmonary artery pressure (from 79 ± 19 to 48 ± 19 mmHg). The patients with proximal disease (Jamieson type 1 or 2) had better survival than those with distal disease (Jamieson type 3 or 4), but there was no significant difference in mortality between FC III and IV. All of the four patients who did not undergo PEA survived for more than 3 years. CONCLUSIONS Significant improvements in symptoms, functional capacity, and hemodynamics were achieved in the CTEPH patients after PEA. However, the overall survival was still unsatisfactory.
Collapse
Affiliation(s)
- Yu-Jhou Chen
- College of Medicine, Chang Gung University, Chang Gung Memorial Hospital
| | | | - Feng-Chun Tsai
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | | | | | | | | | | |
Collapse
|
25
|
Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM, Crumb SR, Dearani JA, Fuller S, Gurvitz M, Khairy P, Landzberg MJ, Saidi A, Valente AM, Van Hare GF. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018; 73:e81-e192. [PMID: 30121239 DOI: 10.1016/j.jacc.2018.08.1029] [Citation(s) in RCA: 491] [Impact Index Per Article: 81.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
26
|
Sonaglioni A, Baravelli M, Cassandro R, Torre O, Elia D, Anzà C, Harari S. Hemodynamic Mechanisms of Exercise-Induced Pulmonary Hypertension in Patients with Lymphangioleiomyomatosis: The Role of Exercise Stress Echocardiography. J Am Soc Echocardiogr 2018; 31:888-901. [DOI: 10.1016/j.echo.2018.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Indexed: 01/23/2023]
|
27
|
Rhinehart JD, Schober KE, Scansen BA, Yildiz V, Bonagura JD. Effect of Body Position, Exercise, and Sedation on Estimation of Pulmonary Artery Pressure in Dogs with Degenerative Atrioventricular Valve Disease. J Vet Intern Med 2017; 31:1611-1621. [PMID: 28865107 PMCID: PMC5697194 DOI: 10.1111/jvim.14814] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 05/18/2017] [Accepted: 07/25/2017] [Indexed: 12/26/2022] Open
Abstract
Background Severity of pulmonary hypertension (PH) in dogs is related to clinical signs and prognosis. Hypothesis/Objectives We hypothesized that Doppler echocardiographic (DE) indices of pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) are influenced by independent factors that create clinically important variability of DE‐based estimates of PH in dogs. Animals Thirty‐eight client owned dogs with naturally acquired degenerative atrioventricular valve disease and tricuspid regurgitation (TR). Methods Dogs were prospectively enrolled, and target variables were acquired during 4 echocardiographic study periods (lateral recumbency, standing, lateral recumbency after a 6‐minute walk test [6MWT], and lateral recumbency after sedation with butorphanol 0.25 mg/kg IM). Statistical methods included repeated measures ANOVA, mixed model analysis, and Chi‐squared test of association. Results There was a significant increase in peak TR flow velocity (TRFV; P < 0.01) after sedation in 78% of dogs, with TRFV increasing by >0.4 m/s in 42% of dogs, independent of stroke volume. A significant effect of study period on DE‐estimated PVR was not found (P = 0.15). There were negligible effects of sonographer, body position, and 6MWT on echocardiographic variables of PH. Clinically relevant cyclic variation of TRFV was found. There was an association between estimation of right atrial pressure based on subjective assessment and estimation based on cranial vena cava collapsibility (P = 0.03). Conclusions and Clinical Importance The increase in TRFV observed with sedation could change assessment of PH severity and impact prognostication and interpretation of treatment response. Further studies with invasive validation are needed.
Collapse
Affiliation(s)
- J D Rhinehart
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, OH
| | - K E Schober
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, OH
| | - B A Scansen
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, OH
| | - V Yildiz
- Center for Biostatistics, The Ohio State University, Columbus, OH
| | - J D Bonagura
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, OH
| |
Collapse
|
28
|
van Riel ACMJ, Systrom DM, Oliveira RKF, Landzberg MJ, Mulder BJM, Bouma BJ, Maron BA, Shah AM, Waxman AB, Opotowsky AR. Hemodynamic and metabolic characteristics associated with development of a right ventricular outflow tract pressure gradient during upright exercise. PLoS One 2017. [PMID: 28636647 PMCID: PMC5479527 DOI: 10.1371/journal.pone.0179053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background We recently reported a novel observation that many patients with equal resting supine right ventricular(RV) and pulmonary artery(PA) systolic pressures develop an RV outflow tract(RVOT) pressure gradient during upright exercise. The current work details the characteristics of patients who develop such an RVOT gradient. Methods We studied 294 patients (59.7±15.5 years-old, 49% male) referred for clinical invasive cardiopulmonary exercise testing, who did not have a resting RVOT pressure gradient defined by the simultaneously measured peak-to-peak difference between RV and PA systolic pressures. Results The magnitude of RVOT gradient did not correspond to clinical or hemodynamic findings suggestive of right heart failure; rather, higher gradients were associated with favorable exercise findings. The presence of a high peak RVOT gradient (90th percentile, ≥33mmHg) was associated with male sex (70 vs. 46%, p = 0.01), younger age (43.6±17.7 vs. 61.8±13.9 years, p<0.001), lower peak right atrial pressure (5 [3–7] vs. 8 [4–12]mmHg, p<0.001), higher peak heart rate (159±19 vs. 124±26 beats per minute, p<0.001), and higher peak cardiac index (8.3±2.3 vs. 5.7±1.9 L/min/m2, p<0.001). These associations persisted when treating peak RVOT as a continuous variable and after age and sex adjustment. At peak exercise, patients with a high exercise RVOT gradient had both higher RV systolic pressure (78±11 vs. 66±17 mmHg, p<0.001) and lower PA systolic pressure (34±8 vs. 50±19 mmHg, p<0.001). Conclusions Development of a systolic RV-PA pressure gradient during upright exercise is not associated with an adverse hemodynamic exercise response and may represent a normal physiologic finding in aerobically fit young people.
Collapse
Affiliation(s)
- Annelieke C. M. J. van Riel
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - David M. Systrom
- Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Rudolf K. F. Oliveira
- Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), SP, Brazil
| | - Michael J. Landzberg
- Department of Cardiology, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts, United States of America
- Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Barbara J. M. Mulder
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Berto J. Bouma
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Bradley A. Maron
- Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Amil M. Shah
- Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Aaron B. Waxman
- Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Alexander R. Opotowsky
- Department of Cardiology, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts, United States of America
- Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| |
Collapse
|
29
|
Jiang R, Wu C, Pudasaini B, Wang L, Zhao QH, Zhang R, Wu WH, Yuan P, Jing ZC, Liu JM. A novel scoring index by Doppler echocardiography for predicting severe pulmonary hypertension due to chronic lung diseases: a cross-sectional diagnostic accuracy study. Int J Chron Obstruct Pulmon Dis 2017; 12:1741-1751. [PMID: 28652726 PMCID: PMC5476678 DOI: 10.2147/copd.s133854] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Severe pulmonary hypertension (PH) resulting from a chronic lung disease (CLD) (severe CLD-PH) requires more aggressive treatment due to its increased mortality compared with mild PH. Therefore, we developed a Doppler echocardiography scoring index (ESI) to predict severe CLD-PH. Methods A derivation cohort of 107 patients with CLD who underwent echocardiography was classified into two groups, the normal/mild PH group and the severe PH group, based on the right heart catheterization. Meanwhile, we designed the ESI by multivariate logistic regression to validate the predicted outcomes. The ESI was calculated using the following formula: ESI = ESIRVEDTD + ESIPASP + ESIPAd − ESITAPSE. Additionally, the ESI was weighted by +2 points for right ventricular end-diastolic transverse dimension ≥3.8 cm or pulmonary artery diameter ≥2.7 cm, +3 points for systolic pulmonary artery pressure (PASP) ≥61 mmHg, and −3 points for tricuspid annular plane systolic excursion ≥1.65 cm. Results In the derivation cohort, PASP ≥61 mmHg estimated by echocardiography exhibited 80.4% sensitivity and 84.3% specificity with area under receiver-operating characteristic curve of 0.823 (95% CI: 0.797–0.942, P<0.0001). Compared with PASP, ESI ≥1.0 exhibited 91.1% sensitivity and 80.4% specificity, resulting in a net improvement in model performance with a change in the c-statistic from 0.823 to 0.937 and an integrated discrimination improvement of 11.3% (95% CI: 4.5%–18.2%, P=0.001). The ESI was applied to the validation cohort, resulting in 84.2% sensitivity and 81.3% specificity with 82.9% accuracy. Conclusion The ESI showed high capacity for predicting severe CLD-PH, further implying the value of noninvasive examinations in clinic.
Collapse
Affiliation(s)
- Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine
| | - Cheng Wu
- Department of Health Statistics, Second Military Medical University, Shanghai, People's Republic of China
| | - Bigyan Pudasaini
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine
| | - Rui Zhang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine
| | - Wen-Hui Wu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine
| | - Zhi-Cheng Jing
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine
| | - Jin-Ming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine
| |
Collapse
|
30
|
Prins KW, Weir EK, Archer SL, Markowitz J, Rose L, Pritzker M, Madlon-Kay R, Thenappan T. Pulmonary pulse wave transit time is associated with right ventricular-pulmonary artery coupling in pulmonary arterial hypertension. Pulm Circ 2017; 6:576-585. [PMID: 28090301 DOI: 10.1086/688879] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pulmonary pulse wave transit time (pPTT), defined as the time for the systolic pressure pulse wave to travel from the pulmonary valve to the pulmonary veins, has been reported to be reduced in pulmonary arterial hypertension (PAH); however, the underlying mechanism of reduced pPTT is unknown. Here, we investigate the hypothesis that abbreviated pPTT in PAH results from impaired right ventricular-pulmonary artery (RV-PA) coupling. We quantified pPTT using pulsed-wave Doppler ultrasound from 10 healthy age- and sex-matched controls and 36 patients with PAH. pPTT was reduced in patients with PAH compared with controls. Univariate analysis revealed the following significant predictors of reduced pPTT: age, right ventricular fractional area change (RV FAC), tricuspid annular plane excursion (TAPSE), pulmonary arterial pressures (PAP), diastolic pulmonary gradient, transpulmonary gradient, pulmonary vascular resistance, and RV-PA coupling (defined as RV FAC/mean PAP or TAPSE/mean PAP). Although the correlations between pPTT and invasive markers of pulmonary vascular disease were modest, RV FAC (r = 0.64, P < 0.0001), TAPSE (r = 0.67, P < 0.0001), and RV-PA coupling (RV FAC/mean PAP: r = 0.72, P < 0.0001; TAPSE/mean PAP: r = 0.74, P < 0.0001) had the strongest relationships with pPTT. On multivariable analysis, only RV FAC, TAPSE, and RV-PA coupling were independent predictors of pPTT. We conclude that shortening of pPTT in patients with PAH results from altered RV-PA coupling, probably occurring as a result of reduced pulmonary arterial compliance. Thus, pPTT allows noninvasive determination of the status of both the pulmonary vasculature and the response of the RV in patients with PAH, thereby allowing monitoring of disease progression and regression.
Collapse
Affiliation(s)
- Kurt W Prins
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - E Kenneth Weir
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Stephen L Archer
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Jeremy Markowitz
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Lauren Rose
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Marc Pritzker
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Richard Madlon-Kay
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Thenappan Thenappan
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| |
Collapse
|
31
|
Ikeda M, Wakasaki R, Schenning KJ, Swide T, Lee JH, Miller MB, Choi HS, Anderson S, Hutchens MP. Determination of renal function and injury using near-infrared fluorimetry in experimental cardiorenal syndrome. Am J Physiol Renal Physiol 2017; 312:F629-F639. [PMID: 28077373 DOI: 10.1152/ajprenal.00573.2016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 12/19/2016] [Accepted: 01/05/2017] [Indexed: 02/08/2023] Open
Abstract
Cardiorenal syndrome type 1 causes acute kidney injury but is poorly understood; animal models and diagnostic aids are lacking. Robust noninvasive measurements of glomerular filtration rate are required for injury models and clinical use. Several have been described but are untested in translational models and suffer from biologic interference. We developed a mouse model of cardiorenal syndrome and tested the novel near-infrared fluorophore ZW800-1 to assess renal and cardiac function. We performed murine cardiac arrest and cardiopulmonary resuscitation followed by transthoracic echocardiography, 2 and 24 h later. Transcutaneous fluorescence of ZW800-1 bolus dispersion and clearance was assessed with whole animal imaging and compared with glomerular filtration rate (GFR; inulin clearance), tubular cell death (using unbiased stereology), and serum creatinine. Correlation, Bland-Altman, and polar analyses were used to compare GFR with ZW800-1 clearance. Cardiac arrest and cardiopulmonary resuscitation caused reversible cardiac failure, halving fractional shortening of the left ventricle (n = 12, P = 0.03). Acute kidney injury resulted with near-zero GFR and sixfold increase in serum creatinine 24 h later (n = 16, P < 0.01). ZW800-1 biodistribution and clearance were exclusively renal. ZW800-1 t1/2 and clearance correlated with GFR (r = 0.92, n = 31, P < 0.0001). ZW800-1 fluorescence was reduced in cardiac arrest, and cardiopulmonary resuscitation-treated mice compared with sham animals 810 s after injection (P < 0.01) and bolus time-dispersion curves demonstrated that ZW800-1 fluorescence dispersion correlated with left ventricular function (r = 0.74, P < 0.01). Cardiac arrest and cardiopulmonary resuscitation lead to experimental cardiorenal syndrome type 1. ZW800-1, a small near-infrared fluorophore being developed for clinical intraoperative imaging, is favorable for evaluating cardiac and renal function noninvasively.
Collapse
Affiliation(s)
- Mizuko Ikeda
- Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Rumie Wakasaki
- Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Katie J Schenning
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas Swide
- Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jeong Heon Lee
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts; and
| | - M Bernie Miller
- Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Hak Soo Choi
- Gordon Center for Medical Imaging, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts; and
| | - Sharon Anderson
- Division of Nephrology & Hypertension, Oregon Health & Science University, Portland, Oregon
| | - Michael P Hutchens
- Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon;
| |
Collapse
|
32
|
Doutreleau S, Canuet M, Enache I, Di Marco P, Charloux A. Pulmonary Vascular Resistance in Patients With Pulmonary Hypertension: Importance of the Quadratic Velocity-Pressure Relationship - Reply. Circ J 2016; 80:2563-2564. [PMID: 27829589 DOI: 10.1253/circj.cj-16-1077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
33
|
Doutreleau S, Canuet M, Enache I, Di Marco P, Lonsdorfer E, Oswald-Mammoser M, Charloux A. Right Heart Hemodynamics in Pulmonary Hypertension - An Echocardiography and Catheterization Study. Circ J 2016; 80:2019-25. [PMID: 27488283 DOI: 10.1253/circj.cj-16-0206] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Echocardiography (ECHO) plays a key role in both the diagnosis and prognosis of pulmonary hypertension (PH). Many equations have been published to assess right heart hemodynamics using ECHO. The objective of this study was to test the accuracy and precision of different echocardiographic equations in comparison with the right heart catheterization. METHODS AND RESULTS Complete right heart hemodynamic assessments were prospectively obtained from 115 individuals (mean age 66±1 years; 57 males) who had known or suspected PH. Several equations were tested for the estimation of right atrial pressure, mean and systolic pulmonary artery pressure (MPAP), cardiac output, pulmonary capillary wedge pressure (PCWP), and pulmonary vascular resistance (PVR). The accuracy of ECHO was good, with a mean difference <2 mmHg for all of the pressure calculations and ±0.6 L/min for cardiac output. However, the PVR estimation was weak using any one of the formulae. For all the parameters, the precision of ECHO was moderate. The MPAP calculation detected PH with a sensibility of 97% and specificity of 83%. However, ECHO underdiagnosed post-capillary PH. CONCLUSIONS ECHO is a good method for the diagnosis of PH, with an adequate calculation of right pressures, but cannot accurately calculate PCWP and PVR. (Circ J 2016; 80: 2019-2025).
Collapse
|
34
|
Duarte AG, Lin YL, Sharma G. Incidence of right heart catheterization in patients initiated on pulmonary arterial hypertension therapies: A population-based study. J Heart Lung Transplant 2016; 36:220-226. [PMID: 27595194 DOI: 10.1016/j.healun.2016.07.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 06/25/2016] [Accepted: 07/20/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Pulmonary hypertension represents a heterogeneous collection of conditions classified into 5 groups according to pathology, pathophysiology and response to treatment. Right heart catheterization is required to classify patients and before initiation of specific therapy for treatment of pulmonary arterial hypertension. The aim of this study was to determine performance of right heart catheterization in patients prescribed pulmonary arterial hypertension (PAH)-specific medications. METHODS A retrospective review of administrative claims was performed using the Clinformatics Data Mart database. Individuals with an encounter diagnosis of pulmonary hypertension were identified by ICD-9 codes. An initial encounter diagnosis was defined as continuous enrollment for 12 months without a previous ICD-9 diagnosis of pulmonary hypertension. These individuals were followed for 15 months after initial encounter diagnosis. Individuals prescribed PAH-specific medications were assessed for characteristics, comorbidities and performance of echocardiography and right heart catheterization. RESULTS From 2002 to 2011, 15,772 patients had an outpatient visit with a diagnosis of pulmonary hypertension. From the initial group, 969 (6.1%) patients were prescribed PAH-specific medications within 1 year of encounter diagnosis. Oral PAH-specific medications were prescribed to 94.2% of patients. In patients prescribed PAH-specific medications, 91% had an echocardiogram within 1 year of encounter diagnosis. Cardiac catheterization was performed in 407 patients (42%) within 3 months of initial prescription and in 583 patients (60.2%) during the entire study period. CONCLUSION Performance of right heart catheterization was low in this population-based study of patients with an ICD-9 diagnosis code of pulmonary hypertension and taking PAH-specific medications.
Collapse
Affiliation(s)
- Alexander G Duarte
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Texas Medical Branch, Galveston, Texas, USA.
| | - Yu Li Lin
- Office of Biostatistics, University of Texas Medical Branch, Galveston, Texas, USA
| | - Gulshan Sharma
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| |
Collapse
|
35
|
Novo Matos J, Malbon A, Dennler M, Glaus T. Intrapulmonary arteriovenous anastomoses in dogs with severe Angiostrongylus vasorum infection: clinical, radiographic, and echocardiographic evaluation. J Vet Cardiol 2016; 18:110-24. [DOI: 10.1016/j.jvc.2015.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 10/08/2015] [Accepted: 10/14/2015] [Indexed: 11/25/2022]
|
36
|
Guseh JS. The Evolving Landscape of Exercise-Induced Pulmonary Hypertension. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:41. [PMID: 27174296 DOI: 10.1007/s11936-016-0459-5] [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: 11/24/2022]
Abstract
OPINION STATEMENT Normal pulmonary artery pressures at rest, with an exaggerated rise during exercise, characterize exercise-induced pulmonary hypertension. Exercise itself as it relates to this condition is not deleterious, nor does it cause or induce disease. However much like any classical stress test, it is a physiologic probe that aids in disease unmasking. Although more work is required to establish criteria for defining this clinical entity, the phenomenon is real. It remains unknown whether it represents a nascent form of cardiopulmonary disease and whether its genesis predicts fulminant cardiopulmonary disease. Incremental cardiopulmonary exercise testing and the construction of pressure-flow plots to describe the pulmonary vascular response to exercise will be essential in defining this disease. The critical first step remains a consensus definition that will allow for further prospective study focused by a common language.
Collapse
Affiliation(s)
- J Sawalla Guseh
- Department of Medicine, Division of Cardiology, Yawkey Center for Outpatient Care, Massachusetts General Hospital, 5th Floor 32 Fruit Street, Boston, MA, 02114, USA.
| |
Collapse
|
37
|
Tossavainen E, Henein MY, Grönlund C, Lindqvist P. Left Atrial Intrinsic Strain Rate Correcting for Pulmonary Wedge Pressure Is Accurate in Estimating Pulmonary Vascular Resistance in Breathless Patients. Echocardiography 2016; 33:1156-65. [PMID: 27144613 DOI: 10.1111/echo.13226] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES We hypothesized that left atrial deformation during atrial systole (LASRa) correlates with pulmonary capillary wedge pressure (PCWP), thus enabling echo-derived pulmonary vascular resistance (PVR) estimation in a wide range of different subsets of patients. BACKGROUND Various etiologies of pulmonary hypertension (PH) have different mechanisms and treatments for breathlessness. Irrespective of the location of the underlying pulmonary vascular pathology, pre- or postcapillary, the resulting PH is fairly easy to assess by Doppler echocardiography, but PVR remains a challenge. METHODS We prospectively included 46 patients (mean age 61 ± 13 years) in sinus rhythm, who underwent right heart catheterization because of dyspnea. According to the NICE guidelines classification, 22 belonged to group 1 pulmonary artery hypertension (PAH), 19 belonged to group 2 congestive heart failure (CHF), 1 belonged to group 4 chronic thromboembolic pulmonary hypertension (CTEPH), and 4 had normal hemodynamics. Simultaneous Doppler echocardiography using spectral, tissue Doppler, and speckle tracking echocardiography techniques for assessing LA structure and function was performed. RESULTS PCWPrhc correlated with LASRa (r(2) = 0.65, P < 0.001). PCWPecho was calculated using the equation (PCWPecho = 26.12 - 11.09 × LASRa), and the resulting PVR echo strongly correlated with the respective catheter-based measurements PVRrhc (r(2) = 0.69. P < 0.001) with a sensitivity of 85% and specificity of 74% identifying a PVR ≥ 3 WU. CONCLUSIONS Left atrial strain rate during atrial systole correlates closely with pulmonary capillary wedge pressure and consequently the calculated pulmonary vascular resistance, irrespective of the etiology of PH.
Collapse
Affiliation(s)
- Erik Tossavainen
- Department of Cardiology, Heart Center, Umeå University, Umeå, Sweden
| | - Michael Y Henein
- Department of Cardiology, Heart Center, Umeå University, Umeå, Sweden.,Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Christer Grönlund
- Department of Biomedical Engineering - R&D Radiation Sciences, Umeå University, Umeå, Sweden
| | - Per Lindqvist
- Department of Clinical Physiology, Heart Center, Umeå University, Umeå, Sweden.,Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| |
Collapse
|
38
|
Krieger EV, Leary PJ, Opotowsky AR. Pulmonary Hypertension in Congenital Heart Disease: Beyond Eisenmenger Syndrome. Cardiol Clin 2015; 33:599-609, ix. [PMID: 26471823 DOI: 10.1016/j.ccl.2015.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patients with adult congenital heart disease have an increased risk of developing pulmonary hypertension. There are several mechanisms of pulmonary hypertension in patients with adult congenital heart disease, and understanding them requires a systematic approach to define the patient's hemodynamics and physiology. This article reviews the updated classification of pulmonary hypertension in patients with adult congenital heart disease with a focus on pathophysiology, diagnostics, and the evaluation of pulmonary hypertension in special adult congenital heart disease populations.
Collapse
Affiliation(s)
- Eric V Krieger
- Seattle Adult Congenital Heart Service, Division of Cardiology, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA.
| | - Peter J Leary
- Pulmonary Vascular Disease Program, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - Alexander R Opotowsky
- Boston Adult Congenital Heart and Pulmonary Hypertension Service, Department of Cardiology, Boston Children's Hospital and Brigham and Women's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| |
Collapse
|
39
|
Choi BG, Sanai R, Yang B, Young HA, Mazhari R, Reiner JS, Lewis JF. Estimation of cardiac output and pulmonary vascular resistance by contrast echocardiography transit time measurement: a prospective pilot study. Cardiovasc Ultrasound 2014; 12:44. [PMID: 25361851 PMCID: PMC4223835 DOI: 10.1186/1476-7120-12-44] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 10/23/2014] [Indexed: 01/18/2023] Open
Abstract
Background Studies with other imaging modalities have demonstrated a relationship between contrast transit and cardiac output (CO) and pulmonary vascular resistance (PVR). We tested the hypothesis that the transit time during contrast echocardiography could accurately estimate both CO and PVR compared to right heart catheterization (RHC). Methods 27 patients scheduled for RHC had 2D-echocardiogram immediately prior to RHC. 3 ml of DEFINITY contrast followed by a 10 ml saline flush was injected, and a multi-cycle echo clip was acquired from the beginning of injection to opacification of the left ventricle. 2D-echo based calculations of CO and PVR along with the DEFINITY-based transit time calculations were subsequently correlated with the RHC-determined CO and PVR. Results The transit time from full opacification of the right ventricle to full opacification of the left ventricle inversely correlated with CO (r = -0.61, p < 0.001). The transit time from peak opacification of the right ventricle to first appearance in the left ventricle moderately correlated with PVR (r = 0.46, p < 0.01). Previously described echocardiographic methods for the determination of CO (Huntsman method) and PVR (Abbas and Haddad methods) did not correlate with RHC-determined values (p = 0.20 for CO, p = 0.18 and p = 0.22 for PVR, respectively). The contrast transit time method demonstrated reliable intra- (p < 0.0001) and inter-observer correlation (p < 0.001). Conclusions We describe a novel method for the quantification of CO and estimation of PVR using contrast echocardiography transit time. This technique adds to the methodologies used for noninvasive hemodynamic assessment, but requires further validation to determine overall applicability.
Collapse
Affiliation(s)
- Brian G Choi
- The GW Heart & Vascular Institute, The George Washington University, Washington, DC, USA.
| | | | | | | | | | | | | |
Collapse
|
40
|
Maron BA. Hemodynamics should be the primary approach to diagnosing, following, and managing pulmonary arterial hypertension. Can J Cardiol 2014; 31:515-20. [PMID: 25742869 DOI: 10.1016/j.cjca.2014.09.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 08/28/2014] [Accepted: 09/04/2014] [Indexed: 12/18/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a highly morbid cardiopulmonary disease characterized by plexogenic pulmonary arteriole remodelling. Importantly, PAH severity correlates inversely with cardiac output and directly with pulmonary vascular resistance and right atrial pressure, illustrating the importance of accurately measured hemodynamics to define the clinical profile of patients. Currently available noninvasive technology offers only hemodynamic estimates. In contrast, right heart catheterization is the principle diagnostic procedure in PAH and is required to: (1) definitively exclude alternative pulmonary vascular diseases; and (2) quantify hemodynamics at baseline, after vasoreactivity testing, or in response to therapy to prognosticate outcome and guide therapeutic escalation.
Collapse
Affiliation(s)
- Bradley A Maron
- Brigham and Women's Hospital and Harvard Medical School, Department of Medicine, Division of Cardiovascular Medicine, 75 Francis St, Boston, and the Department of Cardiology, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA.
| |
Collapse
|
41
|
Tonelli AR, Conci D, Tamarappoo B, Newman J, Dweik RA. Prognostic value of echocardiographic changes in patients with pulmonary arterial hypertension receiving parenteral prostacyclin therapy. J Am Soc Echocardiogr 2014; 27:733-741.e2. [PMID: 24780356 PMCID: PMC4065815 DOI: 10.1016/j.echo.2014.03.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND It is unknown whether the echocardiographic changes observed after treatment of patients with pulmonary arterial hypertension have prognostic value. METHODS Subjects with pulmonary arterial hypertension, confirmed by right heart catheterization, who underwent Doppler echocardiography before (baseline) and after 1 year of treatment (follow-up) with parenteral prostacyclin analogues were retrospectively identified. Echocardiographic parameters were measured offline by two investigators. RESULTS A total of 48 patients were included (mean age, 45 ± 14 years; 83% women). Compared with baseline, follow-up echocardiography showed reductions in right atrial area (mean percentage change, 12 ± 25%; P < .001), right ventricular (RV) basal and middle cavity dimensions (mean percentage change, 8.5 ± 14% [P < .001] and 6.8 ± 17% [P = .005], respectively), and peak tricuspid regurgitant velocity (mean percentage change, 10 ± 14%; P < .001). Tricuspid annular plane systolic excursion (mean percentage change, 36 ± 43%; P < .001) and RV outflow tract time-velocity integral (mean percentage change, 48 ± 66%; P < .001) increased. During a median follow-up period of 52.5 months (interquartile range, 20.5-80 months), 18 patients (37.5%) died, mostly (n = 15 [83%]) from progression of pulmonary arterial hypertension. The changes in RV end-diastolic area (hazard ratio [HR per 10% decrease, 0.73; 95% confidence interval [CI], 0.57-0.93), tricuspid valve regurgitation velocity (HR per 10 cm/sec decrease, 0.58; 95% CI, 0.37-0.89), RV outflow tract velocity-time integral (HR per 10% increase, 0.90; 95% CI, 0.83-0.98), and subjective RV function (HR per 1 unit of improvement [e.g., from moderate to mild], 0.55; 95% CI, 0.31-0.96) were associated with overall mortality. CONCLUSIONS Echocardiographic parameters that estimate RV systolic pressure and assess RV morphology and function improve after 1 year of prostacyclin analogue treatment, and the degree of change has prognostic implications.
Collapse
Affiliation(s)
- Adriano R. Tonelli
- Staff, Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Diego Conci
- Fellow, Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Balaji Tamarappoo
- Staff, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jennie Newman
- Nurse, Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Raed A Dweik
- Director of Pulmonary Vascular Diseases Program, Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
42
|
Ho WJ, Lin CP, Wang CL, Hsu LA, Yu KH, Luo SF, Chen JY, Hsu TS. Improvement of Right Ventricular Function in Pulmonary Arterial Hypertension with Disease-Specific Therapy - A Clinical Observational Study. ACTA CARDIOLOGICA SINICA 2014; 30:236-244. [PMID: 27122794 PMCID: PMC4804863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 12/20/2013] [Indexed: 06/05/2023]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a serious and progressive disorder that can result in right ventricular (RV) dysfunction and mortality. Consequently, it is important to monitor RV function during management of PAH. The aim of this study was to investigate the change in RV function by echocardiography before and after disease-specific therapy. METHODS We recruited 31 PAH patients with functional class (FC) III or IV. All the patients received a comprehensive assessment before disease-specific therapy was administered, including observation of clinical symptoms, 6-min walk distance (6MWD), serum brain natriuretic peptide (BNP) level, and transthoracic echocardiography. The assessment was repeated 12 weeks after therapy. RESULTS Twenty-eight patients with a mean age of 40 years completed the study, of whom 82% were women. We found that the etiologies were mainly connective tissue disease-associated and idiopathic PAH. Of the patients in our study, 36% received endothelin receptor antagonist and 64% received phosphodiesterase-5 inhibitor. There was a significant improvement in FC after disease-specific therapy (p < 0.001). The 6MWD increased from 326 to 403 m (p < 0.001), and the serum BNP level decreased from 242 to 130 pg/mL (p = 0.008) after treatment. Echocardiography showed significant reduction in the right atrial and RV areas, pulmonary artery pressure, RV free wall thickness, and inferior vena cava diameter. The myocardial performance index and left ventricular eccentricity index were significantly reduced after therapy. CONCLUSIONS For PAH patients in our study, disease-specific therapy for 12 weeks resulted in an improvement in FC, 6MWD, serum BNP levels, and RV function. KEY WORDS Disease-specific therapy; Pulmonary arterial hypertension; Right ventricular function.
Collapse
Affiliation(s)
| | | | | | | | - Kuang-Hui Yu
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shue-Fen Luo
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ji-Yih Chen
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | | |
Collapse
|
43
|
Robinson B, Ebeid M. A simple echocardiographic method to estimate pulmonary vascular resistance. Am J Cardiol 2014; 113:412. [PMID: 24387904 DOI: 10.1016/j.amjcard.2013.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 11/04/2013] [Accepted: 11/04/2013] [Indexed: 11/17/2022]
|
44
|
Opotowsky AR, Santos M, Maron BA, Afilalo J, Waxman AB, Landzberg MJ, Forfia PR. Towards Widespread Noninvasive Assessment of Pulmonary Vascular Resistance in Clinical Practice. J Am Soc Echocardiogr 2014; 27:108-9. [DOI: 10.1016/j.echo.2013.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Indexed: 10/26/2022]
|
45
|
New Aspects of Echocardiographic Assessment of Pulmonary Hypertension. CURRENT CARDIOVASCULAR IMAGING REPORTS 2013. [DOI: 10.1007/s12410-013-9226-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|