1
|
Fayad FH, Sellke FW, Feng J. Pulmonary hypertension associated with cardiopulmonary bypass and cardiac surgery. J Card Surg 2022; 37:5269-5287. [PMID: 36378925 DOI: 10.1111/jocs.17160] [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: 07/25/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIM Pulmonary hypertension (PH) is frequently associated with cardiovascular surgery and is a common complication that has been observed after surgery utilizing cardiopulmonary bypass (CPB). The purpose of this review is to explain the characteristics of PH, the mechanisms of PH induced by cardiac surgery and CPB, treatments for postoperative PH, and future directions in treating PH induced by cardiac surgery and CPB using up-to-date findings. METHODS The PubMed database was utilized to find published articles. RESULTS There are many mechanisms that contribute to PH after cardiac surgery and CPB which involve pulmonary vasomotor dysfunction, cyclooxygenase, the thromboxane A2 and prostacyclin pathway, the nitric oxide pathway, inflammation, and oxidative stress. Furthermore, there are several effective treatments for postoperative PH within different types of cardiac surgery. CONCLUSIONS By possessing a deep understanding of the mechanisms that contribute to PH after cardiac surgery and CPB, researchers can develop treatments for clinicians to use which target the mechanisms of PH and ultimately reduce and/or eliminate postoperative PH. Additionally, learning about the most up-to-date studies regarding treatments can allow clinicians to choose the best treatments for patients who are undergoing cardiac surgery and CPB.
Collapse
Affiliation(s)
- Fayez H Fayad
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Program in Liberal Medical Education, Brown University, Providence, Rhode Island, USA
| | - Frank W Sellke
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Division of Cardiothoracic Surgery, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Jun Feng
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Division of Cardiothoracic Surgery, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| |
Collapse
|
2
|
Inampudi C, Tedford RJ, Hemnes AR, Hansmann G, Bogaard HJ, Koestenberger M, Lang IM, Brittain EL. Treatment of right ventricular dysfunction and heart failure in pulmonary arterial hypertension. Cardiovasc Diagn Ther 2020; 10:1659-1674. [PMID: 33224779 PMCID: PMC7666956 DOI: 10.21037/cdt-20-348] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/13/2020] [Indexed: 01/09/2023]
Abstract
Right heart dysfunction and failure is the principal determinant of adverse outcomes in patients with pulmonary arterial hypertension (PAH). In addition to right ventricular (RV) dysfunction, systemic congestion, increased afterload and impaired myocardial contractility play an important role in the pathophysiology of RV failure. The behavior of the RV in response to the hemodynamic overload is primarily modulated by the ventricular interaction and its coupling to the pulmonary circulation. The presentation can be acute with hemodynamic instability and shock or chronic producing symptoms of systemic venous congestion and low cardiac output. The prognostic factors associated with poor outcomes in hospitalized patients include systemic hypotension, hyponatremia, severe tricuspid insufficiency, inotropic support use and the presence of pericardial effusion. Effective therapeutic management strategies involve identification and effective treatment of the triggering factors, improving cardiopulmonary hemodynamics by optimization of volume to improve diastolic ventricular interactions, improving contractility by use of inotropes, and reducing afterload by use of drugs targeting pulmonary circulation. The medical therapies approved for PAH act primarily on the pulmonary vasculature with secondary effects on the right ventricle. Mechanical circulatory support as a bridge to transplantation has also gained traction in medically refractory cases. The current review was undertaken to summarize recent insights into the evaluation and treatment of RV dysfunction and failure attributable to PAH.
Collapse
Affiliation(s)
- Chakradhari Inampudi
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Harm-Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Irene Marthe Lang
- Division of Cardiology, Department of Medicine, Medical University of Vienna, Vienna
| | - Evan L. Brittain
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Translational and Clinical Cardiovascular Research Center, Nashville, TN, USA
| |
Collapse
|
3
|
Ince C. Personalized physiological medicine. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:308. [PMID: 29297391 PMCID: PMC5751773 DOI: 10.1186/s13054-017-1907-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This paper introduces the concept of personalized physiological medicine that is specifically directed at the needs of the critically ill patient. This differs from the conventional view of personalized medicine, characterized by biomarkers and gene profiling, instead focusing on time-variant changes in the pathophysiology and regulation of various organ systems and their cellular and subcellular constituents. I propose that personalized physiological medicine is composed of four pillars relevant to the critically ill patient. Pillar 1 is defined by the frailty and fitness of the patient and their physiological reserve to cope with the stress of critical illness and therapy. Pillar 2 involves monitoring of the key physiological variables of the different organ systems and their response to disease and therapy. Pillar 3 concerns the evaluation of the success of resuscitation by assessment of the hemodynamic coherence between the systemic and microcirculation and parenchyma of the organ systems. Finally, pillar 4 is defined by the integration of the physiological and clinical data into a time-learning adaptive model of the patient to provide feedback about the function of organ systems and to guide and assess the response to disease and therapy. I discuss each pillar and describe the challenges to research and development that will allow the realization of personalized physiological medicine to be practiced at the bedside for critically ill patients.
Collapse
Affiliation(s)
- Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. .,Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| |
Collapse
|
4
|
Ju CR, Zhang JH, Chen M, Chen RC. Plasma myostatin levels are related to the extent of right ventricular dysfunction in exacerbation of chronic obstructive pulmonary disease. Biomarkers 2016; 22:246-252. [PMID: 27323660 DOI: 10.1080/1354750x.2016.1203999] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate the relationship between plasma myostatin levels and right ventricle (RV) dysfunction (RVD) in acute exacerbation of chronic obstructive pulmonary disease (AECOPD). METHODS The study recruited 84 patients with AECOPD. Plasma myostatin was analyzed and tricuspid annular plane systolic excursion (TAPSE) < 16 mm was used as the main indicator for RVD. RESULTS Plasma myostatin levels were significantly higher in 47 patients with RVD than 37 ones without (P < 0.005). Multivariate regression analysis revealed that myostatin levels correlated significantly with TAPSE values and RV myocardial performance index (p < 0.001) among the study patients. CONCLUSION Plasma myostatin is a potential biomarker for improving diagnosis of RVD in AECOPD.
Collapse
Affiliation(s)
- Chun-Rong Ju
- a State Key Lab of the Respiratory Disease, Guangzhou Institute of Respiratory Disease , First Affiliated Hospital of Guangzhou Medical University , Guangdong , China
| | - Jian-Heng Zhang
- a State Key Lab of the Respiratory Disease, Guangzhou Institute of Respiratory Disease , First Affiliated Hospital of Guangzhou Medical University , Guangdong , China
| | - Miao Chen
- a State Key Lab of the Respiratory Disease, Guangzhou Institute of Respiratory Disease , First Affiliated Hospital of Guangzhou Medical University , Guangdong , China
| | - Rong-Chang Chen
- a State Key Lab of the Respiratory Disease, Guangzhou Institute of Respiratory Disease , First Affiliated Hospital of Guangzhou Medical University , Guangdong , China
| |
Collapse
|
5
|
Ju CR, Chen M, Zhang JH, Lin ZY, Chen RC. Higher Plasma Myostatin Levels in Cor Pulmonale Secondary to Chronic Obstructive Pulmonary Disease. PLoS One 2016; 11:e0150838. [PMID: 26998756 PMCID: PMC4801210 DOI: 10.1371/journal.pone.0150838] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 02/20/2016] [Indexed: 12/18/2022] Open
Abstract
Objective To analyze plasma myostatin levels and investigate their relationship with right ventricular (RV) function in patients with cor pulmonale secondary to chronic obstructive pulmonary disease (COPD). Methods The study recruited 81 patients with advanced COPD and 40 age-matched controls. The patients were divided into two groups: those with cor pulmonale and those without. Echocardiography was used to evaluate RV function and morphology, and the value of tricuspid annular plane systolic excursion (TAPSE) less than 16 mm was considered RV dysfunction. Plasma myostatin levels were analyzed by enzyme-linked immunosorbent assay, and B-type natriuretic peptide (BNP) levels were analyzed as a comparison of myostatin. Results The data detected cor pulmonale in 39/81 patients, with the mean value of TAPSE of 14.3 mm. Plasma myostatin levels (ng/mL) were significantly higher in patients with cor pulmonale (16.68 ± 2.95) than in those without (13.56 ± 3.09), and much higher than in controls (8.79±2.79), with each p<0.01. Significant differences were also found in plasma BNP levels among the three groups (p<0.05). Multivariate regression analysis suggested that myostatin levels were significantly correlated with the values of TAPSE and RV myocardium performance index among the COPD patients, and that BNP levels were significantly correlated only with systolic pulmonary arterial pressure, with each p<0.05. Conclusions Plasma myostatin levels are increased in COPD patients who have cor pulmonale. Stronger correlations of plasma myostatin levels with echocardiographic indexes of the right heart suggest that myostatin might be superior to BNP in the early diagnosis of cor pulmonale in COPD.
Collapse
Affiliation(s)
- Chun-Rong Ju
- State Key Lab of the Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangdong, China
| | - Miao Chen
- State Key Lab of the Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangdong, China
| | - Jian-Heng Zhang
- State Key Lab of the Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangdong, China
| | - Zhi-Ya Lin
- State Key Lab of the Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangdong, China
| | - Rong-Chang Chen
- State Key Lab of the Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangdong, China
| |
Collapse
|
6
|
Alvarez Escudero J, Calvo Vecino JM, Veiras S, García R, González A. Clinical Practice Guideline (CPG). Recommendations on strategy for reducing risk of heart failure patients requiring noncardiac surgery: reducing risk of heart failure patients in noncardiac surgery. ACTA ACUST UNITED AC 2015; 62:359-419. [PMID: 26164471 DOI: 10.1016/j.redar.2015.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/04/2015] [Indexed: 12/29/2022]
Affiliation(s)
- J Alvarez Escudero
- Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain
| | - J M Calvo Vecino
- Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain; Associated Professor and Head of the Department of Anesthesiology, Infanta Leonor University Hospital, Complutense University of Madrid, Madrid, Spain.
| | - S Veiras
- Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain
| | - R García
- Department of Anesthesiology, Puerta del Mar University Hospital. Cadiz, Spain
| | - A González
- Department of Anesthesiology, Puerta de Hierro University Hospital. Madrid, Spain
| | | |
Collapse
|
7
|
Thunberg CA, Gaitan BD, Grewal A, Ramakrishna H, Stansbury LG, Grigore AM. Pulmonary Hypertension in Patients Undergoing Cardiac Surgery: Pathophysiology, Perioperative Management, and Outcomes. J Cardiothorac Vasc Anesth 2013; 27:551-72. [DOI: 10.1053/j.jvca.2012.07.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Indexed: 11/11/2022]
|
8
|
Buckley MS, Feldman JP. Inhaled epoprostenol for the treatment of pulmonary arterial hypertension in critically ill adults. Pharmacotherapy 2010; 30:728-40. [PMID: 20575636 DOI: 10.1592/phco.30.7.728] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease without a cure. The primary treatment goal for patients with this disease is improving pulmonary blood flow through vasodilation of the pulmonary arteries. Several drugs are available that ameliorate walk distance and hemodynamics, but their maximum tolerated doses are limited in critically ill patients with PAH because of systemic vasodilation resulting in hypotension. The ideal vasodilator would be cost-effective, safe, and selective to the pulmonary vasculature; no such agent currently exists. Inhaled nitric oxide selectively reduces pulmonary pressures without systemic hypotension. However, it is expensive, potentially toxic, and requires complex technology for monitoring and administration. Inhaled epoprostenol may be an alternative therapy to minimize systemic hypotension, which often accompanies rapid intravenous titration. To evaluate the safety and efficacy of inhaled epoprostenol in critically ill patients with PAH, we conducted a literature search by using the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases (1966-August 2009) for relevant studies. Case reports and in vitro studies were excluded. Overall, 11 studies met the inclusion criteria. The PAH population included patients requiring cardiac surgery, lung or heart transplantation, or nonspecific intensive care. All trials showed that inhaled epoprostenol significantly decreased pulmonary pressures without lowering systemic blood pressure. The duration of therapy in most studies was 10-15 minutes, with one study evaluating its effects up to an average of 45.6 hours. Pulmonary pressures returned to baseline soon after drug discontinuation. Minimal adverse events were reported. Thus, inhaled epoprostenol in various subgroups of critically ill patients was effective in reducing pulmonary pressures. However, the significance of these effects on improving clinical outcomes remains unknown. Further studies are needed to determine the role of inhaled epoprostenol in critically ill patients with PAH.
Collapse
Affiliation(s)
- Mitchell S Buckley
- Department of Pharmacy, Banner Good Samaritan Medical Center, Phoenix, Arizona 85006, USA.
| | | |
Collapse
|
9
|
Abstract
Pulmonary arterial hypertension (PAH) is a chronic and progressive disease characterized by a persistent elevation of pulmonary artery pressure accompanied by right ventricular hypertrophy (RVH). The current treatment for pulmonary hypertension is limited and only provides symptomatic relief due to unknown cause and pathogenesis of the disease. Both vasoconstriction and structural remodeling (enhanced proliferation of vascular smooth muscle cell) of the pulmonary arteries contribute to the progressive course of PAH, irrespective of different underlying causes. The exact molecular mechanism of PAH, however, is not fully understood. The purpose of this review is to provide recent advances in the mechanistic investigation of PAH. Specifically, this review focuses on nitric oxide, oxidative stress and inflammation and how these factors contribute to the development and progression of PAH. This review also discusses recent and potential therapeutic advancements for the treatment of PAH.
Collapse
|
10
|
Casserly B, Klinger JR. Brain natriuretic peptide in pulmonary arterial hypertension: biomarker and potential therapeutic agent. DRUG DESIGN DEVELOPMENT AND THERAPY 2009; 3:269-87. [PMID: 20054445 PMCID: PMC2802126 DOI: 10.2147/dddt.s4805] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
B-type natriuretic peptide (BNP) is a member of the natriuretic peptide family, a group of widely distributed, but evolutionarily conserved, polypeptide mediators that exert myriad cardiovascular effects. BNP is a potent vasodilator with mitogenic, hypertrophic and pro-inflammatory properties that is upregulated in pulmonary hypertensive diseases. Circulating levels of BNP correlate with mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR) in patients with pulmonary arterial hypertension (PAH). Elevated plasma BNP levels are associated with increased mortality in patients with PAH and a fall in BNP levels after therapy is associated with improved survival. These findings have important clinical implications in that a noninvasive blood test may be used to identify PAH patients at high-risk of decompensation and to guide pulmonary vasodilator therapy. BNP also has several biologic effects that could be beneficial to patients with PAH. However, lack of a convenient method for achieving sustained increases in circulating BNP levels has impeded the development of BNP as a therapy for treating pulmonary hypertension. New technologies that allow transdermal or oral administration of the natriuretic peptides have the potential to greatly accelerate research into therapeutic use of BNP for cor pulmonale and pulmonary vascular diseases. This review will examine the basic science and clinical research that has led to our understanding of the role of BNP in cardiovascular physiology, its use as a biomarker of right ventricular function and its therapeutic potential for managing patients with pulmonary vascular disease.
Collapse
Affiliation(s)
- Brian Casserly
- Division of Pulmonary and Critical Care Medicine, The Memorial Hospital of Rhode Island, Pawtucket, RI, USA
| | | |
Collapse
|
11
|
Casserly B, Klinger JR. Ambrisentan for the treatment of pulmonary arterial hypertension. DRUG DESIGN DEVELOPMENT AND THERAPY 2009; 2:265-80. [PMID: 19920913 PMCID: PMC2761178 DOI: 10.2147/dddt.s3057] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ambrisentan is an endothelin receptor antagonist (ERA) that was recently approved for treatment of pulmonary arterial hypertension (PAH). Endothelin (ET) is a potent vasoconstrictor with mitogenic, hypertrophic and pro-inflammatory properties that is upregulated in pulmonary hypertensive diseases. The biologic effects of ET are mediated by 2 cell surface receptors termed ETA and ETB. ETA mediates the vasoconstrictor effect of ET on vascular smooth muscle, whereas ETB is expressed primarily on vascular endothelial cells where it induces nitric oxide synthesis and acts to clear ET from the circulation. Ambrisentan is the first ETA selective ERA approved for use in the US. Recently published clinical trials in patients with PAH demonstrate improvement in functional capacity and pulmonary hemodynamics similar to other ETA selective and non-selective ERAs. Its once daily dosing and lower incidence of serum aminotransferase elevation offer potential advantages over other ERAs, but further experience with this agent is needed to fully understand its long-term efficacy and safety. This review discusses the endothelin family of proteins and receptors and their role in the pathophysiology of pulmonary hypertensive diseases. It also examines the development process, safety profile and clinical trials that have resulted in ambrisentan being approved for treatment of PAH.
Collapse
Affiliation(s)
- Brian Casserly
- Division of Pulmonary Medicine, The Memorial Hospital of Rhode Island, 593 Eddy Street, Pawtucket, RI 02903, USA
| | | |
Collapse
|