Right ventricular dysfunction in chronic lung disease

Review of Pulmonary Manifestations in Antisynthetase Syndrome

Antisynthetase syndrome (ASyS) is now a widely recognized entity within the spectrum of idiopathic inflammatory myopathies. Initially described in patients with a triad of myositis, arthritis, and interstitial lung disease (ILD), its presentation can be diverse. Additional common symptoms experienced by patients with ASyS include Raynaud's phenomenon, mechanic's hand, and fever. Although there is a significant overlap with polymyositis and dermatomyositis, the key distinction lies in the presence of antisynthetase antibodies (ASAs). Up to 10 ASAs have been identified to correlate with a presentation of ASyS, each having manifestations that may slightly differ from others. Despite the proposal of three classification criteria to aid diagnosis, the heterogeneous nature of patient presentations poses challenges. ILD confers a significant burden in patients with ASyS, sometimes manifesting in isolation. Notably, ILD is also often the initial presentation of ASyS, requiring pulmonologists to remain vigilant for an accurate diagnosis. This article will comprehensively review the various aspects of ASyS, including disease presentation, diagnosis, management, and clinical course, with a primary focus on its pulmonary manifestations.

Effectiveness, Safety, and Costs of Thromboprophylaxis with Enoxaparin or Unfractionated Heparin Among Medical Inpatients With Chronic Obstructive Pulmonary Disease or Heart Failure

Background: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are risk factors for venous thromboembolism (VTE). Enoxaparin and unfractionated heparin (UFH) help prevent hospital-associated VTE, but few studies have compared them in COPD or HF. Objectives: To compare effectiveness, safety, and costs of enoxaparin vs UFH thromboprophylaxis in medical inpatients with COPD or HF. Methods: This retrospective cohort study included adults with COPD or HF from the Premier PINC AI Healthcare Database. Included patients received prophylactic-dose enoxaparin or UFH during a >6-day index hospitalization (the first visit/admission that met selection criteria during the study period) between January 1, 2010, and September 30, 2016. Multivariable regression models assessed independent associations between exposures and outcomes. Hospital costs were adjusted to 2017 US dollars. Patients were followed 90 days postdischarge (readmission period). Results: In the COPD cohort, 114 174 (69%) patients received enoxaparin and 51 011 (31%) received UFH. Among patients with COPD, enoxaparin recipients had 21%, 37%, and 10% lower odds of VTE, major bleeding, and in-hospital mortality during index admission, and 17% and 50% lower odds of major bleeding and heparin-induced thrombocytopenia (HIT) during the readmission period, compared with UFH recipients (all P <.006). In the HF cohort, 58 488 (58%) patients received enoxaparin and 42 726 (42%) received UFH. Enoxaparin recipients had 24% and 10% lower odds of major bleeding and in-hospital mortality during index admission, and 13%, 11%, and 51% lower odds of VTE, major bleeding, and HIT during readmission (all P <.04) compared with UFH recipients. Enoxaparin recipients also had significantly lower total hospital costs during index admission (mean reduction per patient: COPD, 1280 ; H F , 2677) and readmission (COPD, 379 ; H F , 1024). Among inpatients with COPD or HF, thromboprophylaxis with enoxaparin vs UFH was associated with significantly lower odds of bleeding, mortality, and HIT, and with lower hospital costs. Conclusions: This study suggests that thromboprophylaxis with enoxaparin is associated with better outcomes and lower costs among medical inpatients with COPD or HF based on real-world evidence. Our findings underscore the importance of assessing clinical outcomes and side effects when evaluating cost-effectiveness.

Evolution of pulmonary hypertension in interstitial lung disease: a journey through past, present, and future

Interstitial lung diseases (ILD) are a spectrum of disorders often complicated by pulmonary hypertension (PH) in its course. The pathophysiologic mechanism of WHO group 3 PH is different to other forms of PH. The advent of PH is a harbinger for adverse events like mortality and morbidity, implying that the PH component of disease expedites deteriorated clinical outcomes. In fact, WHO group 3 PH due to ILD has the worse prognosis among all groups of PH. Hence, early detection of PH by a comprehensive screening method is paramount. Given considerable overlap in clinical manifestations between ILD and PH, early detection of PH is often elusive. Despite, the treatment of PH due to ILD has been frustrating until recently. Clinical trials utilizing PAH-specific pulmonary vasodilators have been ongoing for years without desired results. Eventually, the INCREASE study (2018) demonstrated beneficial effect of inhaled Treprostinil to treat PH in ILD. In view of this pioneering development, a paradigm shift in clinical approach to this disease phenotype is happening. There is a renewed vigor to develop a well validated screening tool for early detection and management. Currently inhaled Treprostinil is the only FDA approved therapy to treat this phenotype, but emergence of a therapy has opened a plethora of research toward new drug developments. Regardless of all these recent developments, the overall outlook still remains grim in this condition. This review article dwells on the current state of knowledge of pre-capillary PH due to ILD, especially its diagnosis and management, the recent progresses, and future evolutions in this field.

4D-Flow MRI intracardiac flow analysis considering different subtypes of pulmonary hypertension

Intracardiac flow hemodynamic patterns have been considered to be an early sign of diastolic dysfunction. In this study we investigated right ventricular (RV) diastolic dysfunction between patients with pulmonary arterial hypertension (PAH) and pulmonary hypertension with chronic lung disease (PH-CLD) via 4D-Flow cardiac MRI (CMR). Patients underwent prospective, comprehensive CMR for function and size including 4D-Flow CMR protocol for intracardiac flow visualization and analysis. RV early filling phase and peak atrial phase vorticity (E-vorticity and A-vorticity) values were calculated in all patients. Patients further underwent comprehensive Doppler and tissue Doppler evaluation for the RV diastolic dysfunction. In total 13 patients with PAH, 15 patients with PH-CLD, and 10 control subjects underwent the 4D-Flow CMR and echocardiography evaluation for RV diastolic dysfunction. Reduced E-vorticity differentiated PAH and PH-CLD from healthy controls (both p < 0.01) despite the same Doppler E values. E-vorticity was further decreased in PAH patients when compared to PH-CLD group (p < 0.05) with similar Doppler and tissue Doppler markers of diastolic dysfunction. A-vorticity was decreased in both PAH and PH-CLD groups compared to controls but with no difference between the disease groups. E-vorticity correlated with ejection fraction (R = 0.60, p < 0.001), end-systolic volume (R = 0.50, p = 0.001), stroke volume (R = 0.42, p = 0.007), and cardiac output (R = 0.30, p = 0.027). Intracardiac flow analysis using 4D-Flow CMR derived vorticity is a sensitive method to differentiate diastolic dysfunction in patients with different PH etiology and similar Doppler echocardiography profile.

Pulmonary Hypertension Associated with Diffuse Panbronchiolitis That Improved with Erythromycin and Home Oxygen Therapy

Pulmonary hypertension (PH) often complicates chronic lung disease. However, there are few reports of PH associated with diffuse panbronchiolitis, and there is no effective treatment. We herein report a 64-year-old woman diagnosed with PH due to diffuse panbronchiolitis. She received erythromycin, carbocysteine, and home oxygen therapy (1 L O2/min). After 4 months of therapy, the respiratory function (diffusing capacity of the lungs for carbon monoxide: 23.3% to 76.1%) and PH (mean pulmonary arterial pressure: 50 to 28 mmHg; pulmonary vascular resistance: 680 to 518 dynes・sec・cm-5; pre- vs post-therapy, respectively) had improved markedly.

Assessment of Cardiac Dysfunction in Patients With Chronic Obstructive Pulmonary Disease (COPD): A Cross-Sectional Study

BACKGROUND

 Cardiovascular diseases (CVDs) are frequent in patients having chronic obstructive pulmonary disease (COPD). Despite that, comorbid CVDs receive less guideline-recommended screening in this population compared to others. We aimed to evaluate the cardiac function using echocardiography and to assess spirometry, arterial blood gas (ABG) as well as brain natriuretic peptide (BNP) as prognostic indicators of cardiovascular dysfunction in COPD patients.

METHODS

One hundred moderate to very severe COPD patients according to GOLD guidelines with no history of cardiac diseases were recruited from two hospitals in Saudi Arabia and evaluated using electrocardiography (ECG), chest X-ray, BNP, pulmonary functions, ABG analysis, and transthoracic echocardiography. Multiple linear regression analysis was used to determine the predictors of right ventricular (RV) and left ventricular (LV) dysfunction.

RESULTS

Pulmonary hypertension (PH) was detected in 28% of the patients, while 25% had abnormal tricuspid annular plane systolic excursion (TAPSE). Low left ventricular ejection fraction (LVEF) and abnormal LV strain were present in 20%, abnormal right ventricular strain was present in 17%, and abnormal fractional area change (FAC) was detected in 9% of patients. Multiple linear regression analysis was used to explore possible determinants of cardiac function. Age, gender, and the presence of diabetes and hyperlipidemia were significant predictors of cardiac dysfunction in COPD patients. Forced vital capacity (FVC) was an independent predictor of LVEF (odds ratio, OR: 0.424, confidence interval, 95 CI%: 0.025-0.505, p<0.031) and FAC (OR: 0.496, 95 CI%: 0.008-655). Hypoxemia and hypercapnia significantly predict both RV and LV dysfunctions. BNP was an independent predictor of FAC (OR: 0.307, 95 CI%: -0.021, p<0.001).

CONCLUSION

Cardiac abnormalities are common in moderate to very severe COPD patients. Echocardiography could be considered for the assessment of these patients even in the absence of a history of cardiac disease. Pulmonary functions, ABG, and BNP may offer additional predictive information on cardiac functions in COPD patients.

Bleomycin-induced lung injury: Revisiting an old tool to model group III PH associated with pulmonary fibrosis

Pulmonary hypertension (PH) is a chronic disorder of the pulmonary circulation that often associates with other respiratory diseases (i.e., group III PH), leading to worsened symptoms and prognosis, notably when combined with interstitial lung diseases such as pulmonary fibrosis (PF). PH may lead to right ventricular (RV) failure, which accounts for a substantial part of the mortality in chronic lung disease patients. The disappointing results of pulmonary arterial hypertension (PAH)-related therapies in patients with PF emphasize the need to better understand the pathophysiologic mechanisms that drive PH development and progression in this specific setting. In this work, we validated an animal model of group III PH associated with PF (PH-PF), by using bleomycin (BM) intratracheal instillation and characterizing the nature of induced lung and vascular remodeling, including the influence on RV structure and function. To our knowledge, this is the first work describing this dose of BM in Sprague Dawley rats and the effects upon the heart and lungs, using different techniques such as echocardiography, heart catheterization, and histology. Our data shows the successful implementation of a rat model that mimics combined PF-PH, with most features seen in the equivalent human disease, such as lung and arterial remodeling, increased mPAP and RV dysfunction.

Cardiopulmonary disease as sequelae of long-term COVID-19: Current perspectives and challenges

COVID-19 infection primarily targets the lungs, which in severe cases progresses to cytokine storm, acute respiratory distress syndrome, multiorgan dysfunction, and shock. Survivors are now presenting evidence of cardiopulmonary sequelae such as persistent right ventricular dysfunction, chronic thrombosis, lung fibrosis, and pulmonary hypertension. This review will summarize the current knowledge on long-term cardiopulmonary sequelae of COVID-19 and provide a framework for approaching the diagnosis and management of these entities. We will also identify research priorities to address areas of uncertainty and improve the quality of care provided to these patients.

Predictive value of incidental right ventricular abnormalities identified on SPECT for mortality and pulmonary hypertension

BACKGROUND

The clinical significance of incidentally found RV abnormalities on low-risk SPECT studies is not well-defined. The objective of this study was to determine the predictive value of incidental right ventricular (RV) abnormalities identified on single photon emission computed tomography (SPECT) scans for mortality and pulmonary hypertension (PH).

METHODS

We retrospectively analyzed all low-risk SPECT studies in patients without known coronary artery or pulmonary vascular disease, performed at our institution, from 2007-2020. Adjusted Cox proportional hazards models were used to evaluate the association between incidental RV abnormalities on low-risk SPECT studies and outcomes.

RESULTS

Of the 4761 patients included in the analysis, mortality events were present in 494, and echocardiographic PH was present in 619. Incidental RV abnormalities on low-risk SPECT studies were significantly and independently associated with all-cause mortality (HR = 1.41, CI [1.07-1.86], P = 0.0152) and echocardiographic PH (HR = 2.06, CI [1.64-2.60], P < 0.0001).

CONCLUSIONS

These data suggest incidental RV abnormalities found on low-risk SPECT imaging studies are significantly and independently associated with increased mortality and risk of developing echocardiographic PH, and could identify high-risk patients for closer monitoring and additional diagnostic testing.

Group 3 Pulmonary Hypertension: From Bench to Bedside

Pulmonary hypertension (PH) because of chronic lung disease is categorized as Group 3 PH in the most recent classification system. Prevalence of these diseases is increasing over time, creating a growing need for effective therapeutic options. Recent approval of the first pulmonary arterial hypertension therapy for the treatment of Group 3 PH related to interstitial lung disease represents an encouraging advancement. This review focuses on molecular mechanisms contributing to pulmonary vasculopathy in chronic hypoxia, the pathology and epidemiology of Group 3 PH, the right ventricular dysfunction observed in this population and clinical trial data that inform the use of pulmonary vasodilators in Group 3 PH.

Echocardiographic Characteristics of Patients with Anti‐synthetase Syndrome

Right ventricular (RV) dysfunction and pulmonary hypertension (PH) occurs in approximately one‐third of patients with interstitial lung disease (ILD) and is associated with reduced 6‐minute walk distance (6MWD), and increased hospitalizations and mortality. Although the impact of RV dysfunction and PH has been well described in several types of ILD, data is scarce on antisynthetase syndrome. Therefore, we sought to examine the presence of RV dysfunction and PH in patients with antisynthetase syndrome and the impact on clinical outcomes. We conducted a retrospective study of patients with antisynthetase syndrome. Seventy‐five subjects were identified. Fifty‐one (68%) subjects had echocardiographic data. Patients were grouped into those with normal fractional area change (FAC) ≥ 35% and reduced FAC < 35%. Clinical, echocardiographic, and right heart catheterization data were compared between the two groups. Subjects with FAC < 35% had lower diffusion capacity of the lung for carbon monoxide (29% vs. 47%, p = 0.004), fibrotic features on computed tomography of the chest (79% vs. 33%, p = 0.005), larger RV diameter (5.4 vs. 3.9 cm, p < 0.001), higher right atrial pressures (8 vs. 5 mmHg, p = 0.02), and required supplemental oxygen more frequently (100% vs. 44%, p < 0.001) compared to those with FAC ≥ 35%. We found no difference in 6MWD and hospitalizations between the two groups. The presence of RV dysfunction in antisynthetase syndrome may identify patients at risk of poor outcomes.

Accelerated right heart failure due to lung resection in the setting of chronic respiratory failure

A 68-year-old woman with a past medical history of chronic obstructive pulmonary disease and squamous cell carcinoma of the lung with recent right upper and middle lobectomy was admitted for dyspnea and volume overload. She was diagnosed with right-sided heart failure (RHF) through clinical, laboratory, and echocardiographic means. In the setting of chronic respiratory failure, the recent right lung lobectomy was deemed to be the inciting factor of the RHF. The mechanism by which RHF occurs in this situation is multifactorial, and it is essential to undergo pre-operative risk stratification and post-operative monitoring to avoid emergent events. <Learning objective: New-onset right heart failure can be a detrimental complication of lung resection surgery in patients with chronic respiratory failure. With proper pre-operative risk stratification and its corresponding post-operative monitoring, we can anticipate such occurrences and avoid emergent admissions, enabling better outcomes in a high-risk patient population.>.

Association between RS Time in Electrocardiogram and Right Ventricular Functions in Patients with Chronic Obstructive Pulmonary Disease

OBJECTIVE

The occurrence of right ventricular (RV) dysfunction in chronic obstructive pulmonary disease (COPD) results in an increased risk of mortality. We aimed to study the diagnostic value of RS time in the recognition of COPD patients with RV dysfunction.

METHODS

120 consecutive COPD patients were divided into two groups, patients with and without RV dysfunction, and compared them in terms of parameters including RS time. RS time was defined as the longest interval from the beginning of the QRS complex to the nadir of the S- or S'-wave in the inferolateral leads on an electrocardiogram.

RESULTS

RV dysfunction was observed in 36% of consecutive COPD patients with a mean age of 63.4 ± 9.8 years (83.3% male) and a mean forced expiratory volume in 1 s of 1.51 ± 0.62 lt. The heart rate, right QRS axis deviation frequency, S1S2S3 pattern frequency, and RS time (p < 0.01) were significantly higher in the patients with RV dysfunction than in those without. Body surface area, heart rate, and RS time (p < 0.001) were independent predictors of an RV dysfunction. An ROC analysis showed that the best RS time cutoff value for the prediction of RV dysfunction was 60 ms with a sensitivity of 81.4% and a specificity of 74.0%.

CONCLUSION

In patients with COPD, RS time prolongation, which can be easily and quickly determined from the electrocardiogram, may be a marker for RV dysfunction.

Respiratory Complications in Children and Adolescents with Human Immunodeficiency Virus

Respiratory complications comprise a large proportion of the burden of mortality and morbidity in children with human immunodeficiency virus (HIV). HIV-associated lower respiratory tract infection (LRTI) has declined in incidence with early diagnosis and use of antiretroviral therapy (ART) but is widespread in areas with limited access to ART. HIV-exposed uninfected infants have a higher risk of LRTI early in life than unexposed infants. Pulmonary tuberculosis (PTB) presenting as acute or chronic disease is common in highly TB endemic areas. Chronic lung disease is common; preceding LRTI, PTB or late initiation of ART are risk factors.

The Effects of Endobronchial Coil Therapy on Right Ventricular Functions

Lung hyperinflation is an important therapeutic target in symptomatic emphysema patients. Endobronchial therapies that reduce end-expiratory lung volume are increasingly being used in advanced cases. However, there is paucity of data regarding the effects of these therapies on the heart functions. The aim of this study is to evaluate the right ventricular functions before and after the procedure in patients who underwent endobronchial coil therapy (EBCT).Patients who were between 18 and 80 years of age and scheduled for EBCT with GOLD 3-4 were enrolled in the study. Right heart functions were evaluated using MPI, TAS, TAPSE. Right atrium area and maximum velocity of tricuspid regurgitation were also noted.A total of 23 patients were enrolled in the study. 21 patients underwent bilateral intervention, while only 2 patients received unilateral treatment. There was an improvement in MPI (0.49 ± 0.15 vs 0.39 ± 0.11, p < 0.001) and TAS (11.6 (9 - 15) vs 13.2 (9.80 - 17.0), p = 0.001). Peak TRV (2.52 ± 0.6, 2.38 ± 0.6, p = 0.02) and PASP values were lower in the post-operative period (41.15 ± 5.94 vs 36.83 ± 8.01 p = 0.019).In this current study, we found improved echocardiographic RtV parameters in patients who received EBCT treatment.

Right ventricular dysfunction in patients with non-severe idiopathic pulmonary fibrosis: a cross-sectional prospective single-center study

BACKGROUND

Little is known about right ventricular dysfunction in non-advanced idiopathic pulmonary fibrosis (IPF) patients without hypoxemia at rest. We evaluated it at rest and during exercise.

RESEARCH DESIGN AND METHODS

123 IPF patients were evaluated, and 27 met all the following criteria: Gender-Age-Physiology Index score ≤5, modified Medical Research Council dyspnea score ≤3, peripheral oxygen saturation ≥92% at rest, and no history of oxygen therapy. They were submitted to two-dimensional speckle-tracking echocardiography at rest and during cardiopulmonary exercise to analyze right ventricular global longitudinal strain.

RESULTS

Abnormal speckle-tracking echocardiography findings were identified in 10/27 patients (37%), indicating right ventricular (RV) dysfunction. No patients had abnormalities observed in conventional echocardiographic parameters. Significant differences in mPAP were observed between patients with RV dysfunction and those without dysfunction (at rest: 26.0 ± 4.8 vs. 19.1 ± 4.2 mmHg, p = 0.001; during exercise: 51.3 ± 6.4 vs. 36.9 ± 14.7 mmHg, p = 0.002).

CONCLUSIONS

RV dysfunction was detected in 37% of non-advanced IPF patients and early recognition was only possible using speckle-tracking echocardiography. Special attention should be given to these patients as RV dysfunction is suggestive of worse prognosis. These patients could benefit from new specific drugs or even oxygen therapy for transitory hypoxia.

Cardiovascular Changes in Patients With COVID-19 From Wuhan, China

Background: Coronavirus disease 2019 (COVID-19) is rapidly spreading and resulting in a significant loss of life around the world. However, specific information characterizing cardiovascular changes in COVID-19 is limited.

Methods: In this single-centered, observational study, we enrolled 38 adult patients with COVID-19 from February 10 to March 13, 2020. Clinical records, laboratory findings, echocardiography, and electrocardiogram reports were collected and analyzed.

Results: Of the 38 patients enrolled, the median age was 68 years [interquartile range (IQR), 55–74] with a slight female majority (21, 55.3%). Nineteen (50.0%) patients had hypertension. Seven (33.3%) had ST-T segment and T wave changes, and four (19%) had sinus tachycardia. Twenty (52.6%) had an increase in ascending aorta (AAO) diameter, 22 (57.9%) had an increase in left atrium (LA) size, and 28 (73.7%) presented with ventricular diastolic dysfunction. Correlation analysis showed that the AAO diameter was significantly associated with C-reactive protein (r = 0.4313) and creatine kinase-MB (r = 0.0414). LA enlargement was significantly associated with C-reactive protein (r = 0.4377), brain natriuretic peptide (r = 0.7612), creatine kinase-MB (r = 0.4940), and aspartate aminotransferase (r = 0.2947). Lymphocyte count was negatively associated with the AAO diameter (r = −0.5329) and LA enlargement (r = −0.3894).

Conclusions: Hypertension was a common comorbidity among hospitalized patients with COVID-19, and cardiac injury was the most common complication. Changes in cardiac structure and function manifested mainly in the left heart and AAO in these patients. Abnormal AAO and LA size were found to be associated with severe inflammation and cardiac injury. Alternatively, ascending aortic dilation and LA enlargement might be present before infection but characterized the patient at risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Cor pulmonale: the role of traditional and advanced echocardiography in the acute and chronic settings

Cor pulmonale is the condition in which the right ventricle undergoes morphological and/or functional changes due to diseases that affect the lungs, the pulmonary circulation, or the breathing process. Depending on the speed of onset of the pathological condition and subsequent effects on the right ventricle, it is possible to distinguish the acute cor pulmonale from the chronic type of disease. Echocardiography plays a central role in the diagnostic and therapeutic work-up of these patients, because of its non-invasive nature and wide accessibility, providing its greatest usefulness in the acute setting. It also represents a valuable tool for tracking right ventricular function in patients with cor pulmonale, assessing its stability, deterioration, or improvement during follow-up. In fact, not only it provides parameters with prognostic value, but also it can be used to assess the efficacy of treatment. This review attempts to provide the current standards of an echocardiographic evaluation in both acute and chronic cor pulmonale, focusing also on the findings present in the most common pathologies causing this condition.

Incidence and Progression of Echocardiographic Abnormalities in Older Children with Human Immunodeficiency Virus and Adolescents Taking Antiretroviral Therapy: A Prospective Cohort Study

BACKGROUND

A high prevalence of cardiac abnormalities has been reported in children with human immunodeficiency virus (HIV) taking antiretroviral therapy (ART) in sub-Saharan Africa. We investigated the incidence and progression of cardiac abnormalities among children taking ART in Zimbabwe.

METHODS

A prospective cohort study was conducted at a pediatric HIV clinic from 2014 to 2017. Children with HIV aged between 6 and 16 years and taking ART ≥6 months were enrolled. Transthoracic echocardiography was performed at baseline and after 18 months.

RESULTS

Of 197 participants recruited at baseline, 175 (89%; 48% female; median age 12 years, interquartile range 10-14 years) were followed up. The incidences of left and right heart abnormalities were 3.52 and 5.64 per 100 person-years, respectively. Stunting was associated with the development of any cardiac abnormality (adjusted odds ratio 2.59, 95% confidence interval 1.03-6.49; P = .043). Right ventricular (RV) dilatation persisted at follow-up in 92% of participants and left ventricular (LV) diastolic dysfunction in 88%. Cardiac abnormalities present at baseline reverted to normal over the follow-up period in 11 (6%). There was an overall increase in mean z scores for LV, left atrium (LA), RV, interventricular septum, and LV posterior wall diameters at 18 months (P < .001).

CONCLUSIONS

Despite ART, children with HIV have a high incidence of cardiac abnormalities, with only a minority being transient. Mean z scores for LV, LA, RV, interventricular septum, and LV posterior wall diameters increased over a relatively short follow-up period, suggesting the potential for progression of cardiac abnormalities. Longer follow-up is required to understand the clinical implications of these abnormalities.

Exercise Pathophysiology in Interstitial Lung Disease

Interstitial lung disease (ILD) is a heterogeneous group of disorders that primarily affect the lung parenchyma. Patients with ILD have reduced lung volumes, impaired pulmonary gas exchange, and decreased cardiovascular function. These pathologic features of ILD become exacerbated during physical exertion, leading to exercise intolerance and abnormally high levels of exertional dyspnea. In this review, the authors summarize the primary pathophysiologic features of patients with ILD and their effect on the integrative response to exercise.

Cardiopulmonary dysfunction in perinatally HIV-infected South African adolescents on antiretroviral therapy: baseline findings from the Cape Town Adolescent Antiretroviral Cohort

INTRODUCTION

Antiretroviral therapy (ART) has reduced morbidity and mortality in sub-Saharan Africa, but the burden of coexistent cardiopulmonary disease in perinatally HIV-positive adolescents on antiretroviral therapy (ART) has not been well described. The aim of this study was to investigate the prevalence and associations of cardiopulmonary dysfunction in adolescents with perinatally acquired HIV on ART.

METHODS

For this cross-sectional analysis, 515 perinatally HIV-positive adolescents ages 9 to 14 years on ART for at least six months, and a comparator group of 110 age-matched HIV-uninfected adolescents were tested between August 2013 and April 2015 using echocardiography, six-minute walk test (6MWT) and spirometry. Those with either abnormal spirometry or abnormal 6MWT and any right or left systolic or diastolic dysfunction or abnormal mean pulmonary arterial pressure were considered as having impaired cardiopulmonary function. Logistic regression was used to investigate determinants of impaired cardiopulmonary function.

RESULTS

Overall, 474 adolescents with perinatally acquired HIV (mean [SD] age, 12 [1.6] years; median [IQR] ART duration, 7 [4.6 to 9.3] years; median [IQR] CD4 count, 712 [571 to 959] cell/mm3 ) and 109 HIV-uninfected adolescents mean (SD) age 11.8 (1.8) years, had successful cardiac and lung function testing. Impaired cardiopulmonary function was detected in 13% of adolescents with perinatally acquired HIV and 8% of HIV-uninfected adolescents, p = 0.136. Among adolescents with perinatally acquired HIV, those with low tricuspid annular plane systolic excursion (TAPSE) had significantly lower mean FEV1 , 1.5 L versus 1.6 L, p = 0.011. Height (OR 0.7, 95%CI 0.5 to 0.9), body mass index (OR 0.7, 95%CI 0.5 to 0.9) and past pulmonary tuberculosis (OR 2.3, 95%CI 1.2 to 4.4) were significantly associated with a low cardiopulmonary function.

CONCLUSIONS

Despite being on ART, cardiopulmonary dysfunction occurs in an appreciable proportion of perinatally HIV-infected adolescents but no significant difference to uninfected controls. This finding requires further exploration. Factors associated with dysfunction may be amenable to public health interventions to reduce cardiopulmonary disease in this population.

Alterations in cardiovascular function in an experimental model of lung fibrosis and pulmonary hypertension

NEW FINDINGS

What is the central question of this study? We have evaluated changes in cardiovascular physiology using echocardiography in an experimental model of lung fibrosis. What is the main finding and its importance? Remarkably, we report changes in cardiovascular function as early as day 7, concomitant with evidence of vascular remodelling. We also report that isolated pulmonary arteries were hypercontractile in response to a thromboxane A2 agonist. These findings are significant because the development of pulmonary hypertension is one of the most significant predictors of mortality in patients with lung fibrosis, where there are no available therapies and a lack of animal models.

ABSTRACT

Group III pulmonary hypertension is observed in patients with chronic lung diseases such as chronic obstructive pulmonary disease or idiopathic pulmonary fibrosis. Pulmonary hypertension (PH) develops as a result of extensive pulmonary vascular remodelling and resultant changes in vascular tone that can lead to right ventricle hypertrophy. This eventually leads to right heart failure, which is the leading indicator of mortality in patients with idiopathic pulmonary fibrosis. Treatments for group III PH are not available, in part owing to a lack of viable animal models. Here, we have evaluated the cardiovascular changes in a model of lung fibrosis and PH. Data obtained from this study indicated that structural alterations in the right heart, such as right ventricular wall hypertrophy, occurred as early as day 14, and similar increases in right ventricle chamber size were seen between days 21 and 28. These structural changes were correlated with decreases in the systolic function of the right ventricle and right ventricular cardiac output, which also occurred between the same time points. Characterization of pulmonary artery dynamics also highlighted that PH might be occurring as early as day 21, indicated by reductions in the velocity-time integral; however, evidence for PH is apparent as early as day 7, indicated by the significant reduction in pulmonary acceleration time values. These changes are consistent with evidence of vascular remodelling observed histologically starting on day 7. In addition, we report hyperactivity of bleomycin-exposed pulmonary arteries to a thromboxane A2 receptor (Tbxa2r) agonist.

The Dark Side of the Moon: The Right Ventricle

The aim of this review article is to summarize current knowledge of the pathophysiology underlying right ventricular failure (RVF), focusing, in particular, on right ventricular assessment and prognosis. The right ventricle (RV) can tolerate volume overload well, but is not able to sustain pressure overload. Right ventricular hypertrophy (RVH), as a response to increased afterload, can be adaptive or maladaptive. The easiest and most common way to assess the RV is by two-dimensional (2D) trans-thoracic echocardiography measuring surrogate indexes, such as tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tissue Doppler velocity of the lateral aspect of the tricuspid valvular plane. However, both volumes and function are better estimated by 3D echocardiography and cardiac magnetic resonance (CMR). The prognostic role of the RV in heart failure (HF), pulmonary hypertension (PH), acute myocardial infarction (AMI), and cardiac surgery has been overlooked for many years. However, several recent studies have placed much greater importance on the RV in prognostic assessments. In conclusion, RV dimensions and function should be routinely assessed in cardiovascular disease, as RVF has a significant impact on disease prognosis. In the presence of RVF, different therapeutic approaches, either pharmacological or surgical, may be beneficial.

Wnt5a is associated with right ventricular dysfunction and adverse outcome in dilated cardiomyopathy

The Wingless (Wnt) pathway has been implicated in the pathogenesis of dilated cardiomyopathy (DCM). To explore the role of Wnt modulators Wnt5a and sFRP3 in DCM patients we analyzed the expression of Wnt5a and sFRP3 in plasma and myocardium of DCM patients and evaluated their effects on NFAT luciferase activity in neonatal mouse cardiomyocytes. Elevated circulating Wnt5a (n = 102) was associated with increased pulmonary artery pressures, decreased right ventricular function and adverse outcome, with a stronger association in more severely affected patients. A higher Wnt5a/sFRP3 ratio (n = 25) was found in the right ventricle vs. the left ventricle and was correlated with NFAT activation as well as pulmonary artery pressures. Wnt5a induced NFAT activation and sFRP3 release in cardiomyocytes in vitro, while sFRP3 antagonized Wnt5a. Wnt5a is associated with right ventricular dysfunction and adverse outcome in DCM patients and may promote the progression of DCM through NFAT signaling.

Pulmonary Hypertension Associated with Idiopathic Pulmonary Fibrosis: Current and Future Perspectives

Pulmonary hypertension (PH) is commonly present in patients with chronic lung diseases such as Chronic Obstructive Pulmonary Disease (COPD) or Idiopathic Pulmonary Fibrosis (IPF) where it is classified as Group III PH by the World Health Organization (WHO). PH has been identified to be present in as much as 40% of patients with COPD or IPF and it is considered as one of the principal predictors of mortality in patients with COPD or IPF. However, despite the prevalence and fatal consequences of PH in the setting of chronic lung diseases, there are limited therapies available for patients with Group III PH, with lung transplantation remaining as the most viable option. This highlights our need to enhance our understanding of the molecular mechanisms that lead to the development of Group III PH. In this review we have chosen to focus on the current understating of PH in IPF, we will revisit the main mediators that have been shown to play a role in the development of the disease. We will also discuss the experimental models available to study PH associated with lung fibrosis and address the role of the right ventricle in IPF. Finally we will summarize the current available treatment options for Group III PH outside of lung transplantation.

Relationship of Right Ventricular Size and Function with Respiratory Status in Duchenne Muscular Dystrophy

The relationship between pulmonary function and right ventricle (RV) in Duchenne muscular dystrophy (DMD) has not been evaluated. Using cardiac magnetic resonance (CMR), we describe the relationship of RV size and function with spirometry in a DMD cohort. Fifty-seven boys undergoing CMR and pulmonary function testing within 1 month at a single center (2013-2015) were enrolled. Comparisons of RV ejection fraction (RVEF) and end-diastolic volume index (RVEDVI) were made across categories of percent forced vital capacity (FVC%), and relationships were assessed. Mean age was 15.5 ± 3.5 years. Spirometry and CMR were performed within 3.9 ± 4.1 days. Median FVC% was 92.0 % (67.5-116.5 %). Twenty-three (40 %) patients had abnormal FVC% (<80 %) of which 13 (57 %) had mild (FVC% 60-79 %), 6 (26 %) had moderate (FVC% 40-59 %), and 4 (17 %) had severe (FVC <40 %) reductions. Mean RVEF was 58.3 ± 3.7 %. Patients with abnormal FVC% were older and had lower RVEF and RVEDVI. Both RVEF and RVEDVI were significantly associated with FVC% (r = 0.31, p = 0.02 and r = 0.39, p = 0.003, respectively). In a large DMD cohort, RVEF and RVEDVI were related to FVC%. Worsening respiratory status may guide monitoring of cardiac function in these patients.

Higher Plasma Myostatin Levels in Cor Pulmonale Secondary to Chronic Obstructive Pulmonary Disease

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.

RV diastolic dysfunction: time to re-evaluate its importance in heart failure

Right ventricular (RV) diastolic dysfunction was first reported as an indicator for the assessment of ventricular dysfunction in heart failure a little over two decades ago. However, the underlying mechanisms and precise role of RV diastolic dysfunction in heart failure remain poorly described. Complexities in the structure and function of the RV make the detailed assessment of the contractile performance challenging when compared to its left ventricular (LV) counterpart. LV dysfunction is known to directly affect patient outcome in heart failure. As such, the focus has therefore been on LV function. Nevertheless, a strategy for the diagnosis and assessment of RV diastolic dysfunction has not been established. Here, we review the different causal mechanisms underlying RV diastolic dysfunction, summarising the current assessment techniques used in a clinical environment. Finally, we explore the role of load-independent indices of RV contractility, derived from the conductance technique, to fully interrogate the RV and expand our knowledge and understanding of RV diastolic dysfunction. Accurate assessment of RV contractility may yield further important prognostic information that will benefit patients with diastolic heart failure.

Inhaled nitric oxide in cardiac surgery: Evidence or tradition?

Inhaled nitric oxide (iNO) therapy as a selective pulmonary vasodilator in cardiac surgery has been one of the most significant pharmacological advances in managing pulmonary hemodynamics and life threatening right ventricular dysfunction and failure. However, this remarkable story has experienced a roller-coaster ride with high hopes and nearly universal demonstration of physiological benefits but disappointing translation of these benefits to harder clinical outcomes. Most of our understanding on the iNO field in cardiac surgery stems from small observational or single centre randomised trials and even the very few multicentre trials fail to ascertain strong evidence base. As a consequence, there are only weak clinical practice guidelines on the field and only European expert opinion for the use of iNO in routine and more specialised cardiac surgery such as heart and lung transplantation and left ventricular assist device (LVAD) insertion. In this review the authors from a specialised cardiac centre in the UK with a very high volume of iNO usage provide detailed information on the early observations leading to the European expert recommendations and reflect on the nature and background of these recommendations. We also provide a summary of the progress in each of the cardiac subspecialties for the last decade and initial survey data on the views of senior anaesthetic and intensive care colleagues on these recommendations. We conclude that the combination of high price tag associated with iNO therapy and lack of substantial clinical evidence is not sustainable on the current field and we are risking loosing this promising therapy from our daily practice. Overcoming the status quo will not be easy as there is not much room for controlled trials in heart transplantation or in the current atmosphere of LVAD implantation. However, we call for international cooperation to conduct definite studies to determine the place of iNO therapy in lung transplantation and high risk mitral surgery. This will require new collaboration between the pharmaceutical companies, national grant agencies and the clinical community. Until these trials are realized we should gather multi-institutional experience from large retrospective studies and prospective data from a new international registry. We must step up international efforts if we wish to maintain the iNO modality in the armamentarium of hemodynamic tools for the perioperative management of our high risk cardiac surgical patients.

IL-18 neutralization during alveolar hypoxia improves left ventricular diastolic function in mice

AIM

In patients, an association exists between pulmonary diseases and diastolic dysfunction of the left ventricle (LV). We have previously shown that alveolar hypoxia in mice induces LV diastolic dysfunction and that mice exposed to hypoxia have increased levels of circulating interleukin-18 (IL-18), suggesting involvement of IL-18 in development of diastolic dysfunction. IL-18 binding protein (IL-18BP) is a natural inhibitor of IL-18. In this study, we hypothesized that neutralization of IL-18 during alveolar hypoxia would improve LV diastolic function.

METHODS

Mice were exposed to 10% oxygen for 2 weeks while treated with IL-18BP or vehicle. Cardiac function and morphology were measured using echocardiography, intraventricular pressure measurements and magnetic resonance imaging (MRI). For characterization of molecular changes in the heart, both real-time PCR and Western blotting were performed. ELISA technique was used to measure levels of circulating cytokines.

RESULTS

As expected, exposure to hypoxia-induced LV diastolic dysfunction, as shown by prolonged time constant of isovolumic relaxation (τ). Improved relaxation with IL-18BP treatment was demonstrated by a significant reduction towards control τ values. Decreased levels of phosphorylated phospholamban (P-PLB) in hypoxia, but normalization by IL-18BP treatment suggest a role for IL-18 in regulation of calcium-handling proteins in hypoxia-induced diastolic dysfunction. In addition, MRI showed less increase in right ventricular (RV) wall thickness in IL-18BP-treated animals exposed to hypoxia, indicating an effect on RV hypertrophy.

CONCLUSION

Neutralization of IL-18 during alveolar hypoxia improves LV diastolic function and partly prevents RV hypertrophy.

Pulmonary hypertension and right heart dysfunction in chronic lung disease

Group 3 pulmonary hypertension (PH) is a common complication of chronic lung disease (CLD), including chronic obstructive pulmonary disease (COPD), interstitial lung disease, and sleep-disordered breathing. Development of PH is associated with poor prognosis and may progress to right heart failure, however, in the majority of the patients with CLD, PH is mild to moderate and only a small number of patients develop severe PH. The pathophysiology of PH in CLD is multifactorial and includes hypoxic pulmonary vasoconstriction, pulmonary vascular remodeling, small vessel destruction, and fibrosis. The effects of PH on the right ventricle (RV) range between early RV remodeling, hypertrophy, dilatation, and eventual failure with associated increased mortality. The golden standard for diagnosis of PH is right heart catheterization, however, evidence of PH can be appreciated on clinical examination, serology, radiological imaging, and Doppler echocardiography. Treatment of PH in CLD focuses on management of the underlying lung disorder and hypoxia. There is, however, limited evidence to suggest that PH-specific vasodilators such as phosphodiesterase-type 5 inhibitors, endothelin receptor antagonists, and prostanoids may have a role in the treatment of patients with CLD and moderate-to-severe PH.