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Fadah K, Arrington K, Khalafi S, Brockman M, Garcia H, Alkhateeb H, Mukherjee D, Nickel NP. Insights Into Differences in Pulmonary Hemodynamics in Hispanic Patients With Pulmonary Arterial Hypertension. Cardiol Res 2024; 15:117-124. [PMID: 38645831 PMCID: PMC11027778 DOI: 10.14740/cr1618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/01/2024] [Indexed: 04/23/2024] Open
Abstract
Background Emerging data suggest that Hispanic patients with pulmonary arterial hypertension (PAH) exhibit improved survival rates compared to individuals of other ethnicities with similar baseline hemodynamics. However, the underlying reasons for this survival advantage remain unclear. This study focused on comparing pulmonary hemodynamics in Hispanic and non-Hispanic PAH patients and how these differences may contribute to varied clinical outcomes. Methods A retrospective analysis of right heart catheterization data was conducted on a treatment-naive PAH patient cohort from a single center. Results Over a 10-year period, a total of 226 PAH patients were identified, of which 138 (61%) were Hispanic and 88 (39%) were non-Hispanic. Hispanic patients presented with lower pulmonary artery pressures, lower pulmonary vascular resistance, and exhibited significantly higher pulmonary arterial compliance (PAc). Hispanic patients had better 5-year survival rates. Conclusions This study highlights the importance of exploring phenotypic differences in ethnically diverse PAH cohorts.
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Affiliation(s)
- Kahtan Fadah
- Division of Cardiovascular Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, TX, USA
| | - Kedzie Arrington
- Paul Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, TX, USA
| | - Seyed Khalafi
- Paul Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, TX, USA
| | - Michael Brockman
- Department of Internal Medicine, Division of Pulmonology and Critical Care Medicine, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Hernando Garcia
- Department of Internal Medicine, Division of Pulmonology and Critical Care Medicine, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Haider Alkhateeb
- Division of Cardiovascular Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, TX, USA
| | - Nils P. Nickel
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, TX, USA
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Yim IHW, Parker KH, Drury NE, Lim HS. Pulmonary artery wave intensity analysis in pulmonary hypertension associated with heart failure and reduced left ventricular ejection fraction. Pulm Circ 2024; 14:e12345. [PMID: 38348196 PMCID: PMC10859878 DOI: 10.1002/pul2.12345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/27/2023] [Accepted: 01/26/2024] [Indexed: 02/15/2024] Open
Abstract
Wave intensity analysis (WIA) uses simultaneous changes in pressure and flow velocity to determine wave energy, type, and timing of traveling waves in the circulation. In this study, we characterized wave propagation in the pulmonary artery in patients with pulmonary hypertension associated with left-sided heart disease (PHLHD) and the effects of dobutamine. During right heart catheterization, pressure and velocity data were acquired using a dual-tipped pressure and Doppler flow sensor wire (Combowire; Phillips Volcano), and processed offline using customized Matlab software (MathWorks). Patients with low cardiac output underwent dobutamine challenge. Twenty patients with PHLHD (all heart failure with reduced left ventricular ejection fraction) were studied. Right ventricular systole produced a forward compression wave (FCW), followed by a forward decompression wave (FDW) during diastole. Wave reflection manifesting as backward compression wave (BCW) following the FCW was observed in 14 patients. Compared to patients without BCW, patients with BCW had higher mean pulmonary artery pressure (28.7 ± 6.12 vs. 38.6 ± 6.5 mmHg, p = 0.005), and lower pulmonary arterial capacitance (PAC: 2.88 ± 1.75 vs. 1.73 ± 1.16, p = 0.002). Pulmonary vascular resistance was comparable. Mean pulmonary artery pressure of 34.5 mmHg (area under the curve [AUC]: 0.881) and PAC of 2.29 mL/mmHg (AUC: 0.833) predicted BCW. The magnitude of the FCW increased with dobutamine (n = 11) and correlated with pulmonary artery wedge pressure. Wave reflection in PHLHD is more likely at higher pulmonary artery pressures and lower PAC and the magnitude of reflected waves correlated with pulmonary artery wedge pressure. Dobutamine increased FCW but did not affect wave reflection.
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Affiliation(s)
- Ivan H. W. Yim
- Department of Cardiac SurgeryUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
- Institute of Cardiovascular SciencesUniversity of BirminghamBirminghamUK
| | - Kim H. Parker
- Department of Biomedical EngineeringImperial CollegeLondonUK
| | - Nigel E. Drury
- Department of Cardiac SurgeryUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
- Institute of Cardiovascular SciencesUniversity of BirminghamBirminghamUK
| | - Hoong Sern Lim
- Department of Cardiac SurgeryUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
- Institute of Cardiovascular SciencesUniversity of BirminghamBirminghamUK
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Dandel M. Cardiological Challenges Related to Long-Term Mechanical Circulatory Support for Advanced Heart Failure in Patients with Chronic Non-Ischemic Cardiomyopathy. J Clin Med 2023; 12:6451. [PMID: 37892589 PMCID: PMC10607800 DOI: 10.3390/jcm12206451] [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: 08/16/2023] [Revised: 09/28/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023] Open
Abstract
Long-term mechanical circulatory support by a left ventricular assist device (LVAD), with or without an additional temporary or long-term right ventricular (RV) support, is a life-saving therapy for advanced heart failure (HF) refractory to pharmacological treatment, as well as for both device and surgical optimization therapies. In patients with chronic non-ischemic cardiomyopathy (NICM), timely prediction of HF's transition into its end stage, necessitating life-saving heart transplantation or long-term VAD support (as a bridge-to-transplantation or destination therapy), remains particularly challenging, given the wide range of possible etiologies, pathophysiological features, and clinical presentations of NICM. Decision-making between the necessity of an LVAD or a biventricular assist device (BVAD) is crucial because both unnecessary use of a BVAD and irreversible right ventricular (RV) failure after LVAD implantation can seriously impair patient outcomes. The pre-operative or, at the latest, intraoperative prediction of RV function after LVAD implantation is reliably possible, but necessitates integrative evaluations of many different echocardiographic, hemodynamic, clinical, and laboratory parameters. VADs create favorable conditions for the reversal of structural and functional cardiac alterations not only in acute forms of HF, but also in chronic HF. Although full cardiac recovery is rather unusual in VAD recipients with pre-implant chronic HF, the search for myocardial reverse remodelling and functional improvement is worthwhile because, for sufficiently recovered patients, weaning from VADs has proved to be feasible and capable of providing survival benefits and better quality of life even if recovery remains incomplete. This review article aimed to provide an updated theoretical and practical background for those engaged in this highly demanding and still current topic due to the continuous technical progress in the optimization of long-term VADs, as well as due to the new challenges which have emerged in conjunction with the proof of a possible myocardial recovery during long-term ventricular support up to levels which allow successful device explantation.
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Affiliation(s)
- Michael Dandel
- German Centre for Heart and Circulatory Research (DZHK), 10785 Berlin, Germany
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Tunthong R, Salama AA, Lane CM, Fine NM, Anand V, Padang R, Thaden JJ, Pislaru SV, Kane GC. Right ventricular systolic strain in patients with pulmonary hypertension: clinical feasibility, reproducibility, and correlation with ejection fraction. J Echocardiogr 2023; 21:105-112. [PMID: 36451073 DOI: 10.1007/s12574-022-00593-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 10/22/2022] [Accepted: 11/11/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Right ventricular (RV) systolic function is the major determinant of prognosis in patients with pulmonary hypertension (PH) with quantitative assessment by speckle-tracking strain echocardiography emerging as a viable candidate measure. METHOD We evaluated a prospective cohort of 231 patients with known or suspected PH referred for clinical echocardiography. All underwent measurement of RV free-wall systolic strain by sonographer staff. Digital images were recorded for blinded offline assessment by an expert echocardiographer. Reproducibility was assessed using the analysis methods of Bland-Altman and the Cohen's-Kappa coefficient. RESULTS RV strain was feasible in 213 (92%). The average RV systolic pressure was 59 ± 22 mmHg. RV systolic strain correlated with functional class, NT-proBNP, and the degree of RV enlargement. The average free-wall systolic strain was - 20 ± 7% (range - 2 to - 37%). The RV strain measures (clinical practice versus blinded expert) had an excellent correlation with a normal distribution (R2 0.87, p < 0.0001). By Bland-Altman analysis, the mean difference in measurement was - 1.7% (95% CI - 1.4 to - 2.1) with a correlation of 0.93, p value of < 0.0001. The reproducibility of RV strain for clinically relevant thresholds was also excellent (Kappa coefficients 0.68-0.83). There was no effect on the variability of strain measures across body mass, pulmonary pressures, or rhythm. RV strain correlated with RV diastolic volumes and ejection fraction with RV free wall strain being the best echo predictor for a reduction in ejection fraction. CONCLUSION Here RV systolic strain was found to be highly feasible and reproducible in clinical practice with excellent levels of agreement for clinically relevant thresholds.
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Affiliation(s)
- Ramaimon Tunthong
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
- Non-Invasive Cardiology Department, Bangkok Hospital Headquarters, BDMS, Bangkok, Thailand
| | - Abdalla A Salama
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
- Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt
| | - Conor M Lane
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Nowell M Fine
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Vidhu Anand
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ratnasari Padang
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jeremy J Thaden
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Sorin V Pislaru
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Garvan C Kane
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA.
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Kane CJ, Lara-Breitinger KM, Alabdaljabar MS, Nkomo VT, Padang R, Pislaru C, Kane GC, Scott C, Pislaru SV, Lin G. Pulmonary artery pulsatility index in patients with tricuspid valve regurgitation: a simple non-invasive tool for risk stratification. Eur Heart J Cardiovasc Imaging 2023; 24:1210-1221. [PMID: 37097062 DOI: 10.1093/ehjci/jead070] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/23/2023] [Accepted: 03/28/2023] [Indexed: 04/26/2023] Open
Abstract
AIMS Tricuspid valve regurgitation (TR) is a common valvular disease associated with increased mortality. There is a need for tools to assess the interaction between the pulmonary artery (PA) circulation and the right ventricle in patients with TR and to investigate their association with outcomes. The pulmonary artery pulsatility index (PAPi) has emerged as a haemodynamic risk predictor in left heart disease and pulmonary hypertension (PH). Whether PAPi discriminates risk in unselected patients with greater than or equal to moderate TR is unknown. METHODS AND RESULTS In 5079 patients with greater than or equal to moderate TR (regardless of aetiology) and PA systolic and diastolic pressures measured on their first echocardiogram, we compared all-cause mortality at 5 years based on the presence or absence of PH and PAPi levels. A total of 2741 (54%) patients had PH. The median PAPi was 3.0 (IQR 1.9, 4.4). Both the presence of PH and decreasing levels of PAPi were associated with larger right ventricles, worse right ventricular systolic function, higher NT-pro BNP levels, greater degrees of right heart failure, and worse survival. In a subset of patients who had an echo and right heart catheterization within 24 h, the correlation of non-invasive to invasive PA pressures and PAPi levels was very good (r = 0.76). CONCLUSION In patients with greater than or equal to moderate TR with and without PH, lower PAPi is associated with right ventricular dysfunction, right heart failure, and worse survival. Incorporating PA pressure and PAPi may help stratify disease severity in patients with greater than or equal to moderate TR regardless of aetiology.
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Affiliation(s)
- Conor J Kane
- School of Medicine, University College Dublin, Dublin, Ireland
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Kyla M Lara-Breitinger
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | | | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Cristina Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Christopher Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
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Kane CJ, Salama AA, Pislaru C, Kane GC, Pislaru SV, Lin G. Low Pulmonary Artery Pulsatility Index by Echocardiography Is Associated With Increased Mortality in Pulmonary Hypertension. J Am Soc Echocardiogr 2023; 36:189-195. [PMID: 36126823 DOI: 10.1016/j.echo.2022.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 09/08/2022] [Accepted: 09/08/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pulmonary hypertension (PH) is a progressive pulmonary vascular disorder with elevated mortality risk. The pulmonary artery (PA) pulsatility index (PAPi) based on invasively acquired parameters has emerged as a hemodynamic risk predictor. Whether noninvasively derived PAPi (PA pulse pressure divided by right atrial pressure) is valuable is unclear. METHODS Consecutive patients undergoing transthoracic echocardiography for known or suspected PH were included with conventional echocardiographic measures of PA systolic, PA diastolic, and estimated right atrial pressures. In those patients with PH (mean PA pressure > 20 mm Hg), PAPi was divided into 3 groups: <1.5, 1.5 to 3, and >3. Mortality was assessed over 5 years. RESULTS Of 1,045 patients enrolled, 64% had PH. Patients with the lowest PAPi had higher N-terminal-pro hormone B-type natriuretic peptide levels, larger right ventricles (RVs), worse RV systolic function, and greater degrees of tricuspid regurgitation. In patients with PH, PAPi was inversely proportional to the risk of death, with PAPi <3 associated with a 1.96-fold increased risk of death (95% CI, 1.45-2.64, P < .0001). At multivariate analysis, RV longitudinal systolic strain (hazard ratio [HR] = 1.45, 1.24-1.71; P < .0001), PAPi <3 (HR = 1.76, 1.31-2.37; P = .0002), and the presence of a pericardial effusion (HR = 1.64, 1.20-2.26 P = .003) were independently associated with increased mortality. In age- and sex-adjusted models, PAPi was incremental to PA compliance. CONCLUSIONS In patients with PH, low PAPi derived noninvasively by transthoracic echocardiography is associated with markers of right heart failure, RV dysfunction, and worse survival. PAPi could be incorporated into the conventional echo parameters reported in patients with PH and may be a useful predictor of outcome.
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Affiliation(s)
- Conor J Kane
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Abdalla A Salama
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt
| | - Cristina Pislaru
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
| | - Sorin V Pislaru
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Grace Lin
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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Quintero-Martinez JA, Wysokinski WE, Cordova-Madera SN, Mogollon RJ, Garcia-Arango M, Vlazny DT, Houghton DE, Casanegra AI, Villarraga HR. Pulmonary artery capacitance and pulmonary vascular resistance as prognostic indicators in acute pulmonary embolism. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac007. [PMID: 35919120 PMCID: PMC9242029 DOI: 10.1093/ehjopen/oeac007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/28/2021] [Accepted: 02/21/2022] [Indexed: 12/13/2022]
Abstract
Abstract
Aims
The non-invasive calculation of right ventricular (RV) haemodynamics as pulmonary artery (PA) capacitance (PAC) and pulmonary vascular resistance (PVR) have proved to be feasible, easy to perform, and of high prognostic value. We, therefore, evaluated whether baseline PAC and PVR could predict clinical outcomes for patients with acute pulmonary embolism (PE).
Methods and results
We prospectively followed 373 patients [mean (standard deviation) age, 64.1 (14.9) years; 58.4% were men, and 27.9% had cancer] who had acute PE and transthoracic echocardiography within 1 day of diagnosis from 1 March 2013 through 30 June 2020. Pulmonary artery capacitance was calculated as left ventricular stroke volume/(PA systolic pressure − PA diastolic pressure). Pulmonary vascular resistance was calculated as (tricuspid regurgitant velocity/RV outflow tract velocity time integral) × 10 + 0.16. These two variables were calculated retrospectively from the values obtained with transthoracic echocardiography. Pulmonary artery capacitance was acquired in 99 (27%) patients and PVR in 65 (17%) patients. Univariable and bivariable logistic regression analyses, and receiver operating characteristic curves were used to evaluate the ability of these haemodynamic measurements to predict mortality up to 6 months. After using bivariable models to adjust individually for age, cancer, and pulmonary hypertension. Pulmonary vascular resistance was associated with all-cause mortality at 3 months [area under the curve (AUC) 0.75, 95% confidence interval (CI) 0.61–0.86; P = 0.01], and 6 months (AUC 0.81; 95% CI 0.69–0.91; P≤ 0.03). Pulmonary artery capacitance was associated with all-cause mortality at 30 days (AUC 0.95; 95% CI 0.82–0.99; P < 0.001) and 3 months (AUC 0.84; 95% CI 0.65–0.99; P = 0.003).
Conclusion
Non-invasive measurement of RV haemodynamics could provide prognostic information of patients with acute PE. Pulmonary artery capacitance and PVR are potentially important predictors of all-cause mortality in these patients and should be explored in future studies.
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Affiliation(s)
- Juan A Quintero-Martinez
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
| | - Waldemar E Wysokinski
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
| | - Sandra N Cordova-Madera
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
| | - Renzo J Mogollon
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
| | - Mariana Garcia-Arango
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
| | - Danielle T Vlazny
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
| | - Damon E Houghton
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
| | - Ana I Casanegra
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
| | - Hector R Villarraga
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
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Muneuchi J, Ezaki H, Sugitani Y, Watanabe M. Comprehensive assessments of pulmonary circulation in children with pulmonary hypertension associated with congenital heart disease. Front Pediatr 2022; 10:1011631. [PMID: 36313863 PMCID: PMC9614099 DOI: 10.3389/fped.2022.1011631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Pulmonary hypertension associated with congenital heart disease (CHD-PH) encompasses different conditions confounded by the left-to-right shunt, left heart obstruction, ventricular dysfunction, hypoxia due to airway obstruction, dysplasia/hypoplasia of the pulmonary vasculature, pulmonary vascular obstructive disease, and genetic variations of vasoactive mediators. Pulmonary input impedance consists of the pulmonary vascular resistance (Rp) and capacitance (Cp). Rp is calculated as the transpulmonary pressure divided by the pulmonary cardiac output, whereas Cp is calculated as the pulmonary stroke volume divided by the pulmonary arterial pulse pressure. The plots of Rp and Cp demonstrate a unique hyperbolic relationship, namely, the resistor-capacitor coupling curve, which represents the pulmonary vascular condition. The product of Rp and Cp is the exponential pressure decay, which refers to the time constant. Alterations in Cp are more considerable in CHD patients at an early stage of developing pulmonary hypertension or with excessive pulmonary blood flow due to a left-to-right shunt. The importance of Cp has gained attention because recent reports have shown that low Cp potentially reflects poor prognosis in patients with CHD-PH and idiopathic pulmonary hypertension. It is also known that Cp levels decrease in specific populations, such as preterm infants and trisomy 21. Therefore, both Rp and Cp should be individually evaluated in the management of children with CHD-PH who have different disease conditions.
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Affiliation(s)
- Jun Muneuchi
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization
| | - Hiroki Ezaki
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization
| | - Yuichiro Sugitani
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization
| | - Mamie Watanabe
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization
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Nakagawa A, Yasumura Y, Yoshida C, Okumura T, Tateishi J, Yoshida J, Abe H, Tamaki S, Yano M, Hayashi T, Nakagawa Y, Yamada T, Dohi T, Nakatani D, Hikoso S, Sakata Y. Prognostic Importance of Pulmonary Arterial Capacitance in Acute Decompensated Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2021; 10:e023043. [PMID: 34612057 PMCID: PMC8751883 DOI: 10.1161/jaha.121.023043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Although the prognostic importance of pulmonary arterial capacitance (PAC; stroke volume/pulmonary arterial pulse pressure) has been elucidated in heart failure with reduced ejection fraction, whether its significance in patients suffering from heart failure with preserved ejection fraction is not known. We aimed to examine the association of PAC with outcomes in inpatients with heart failure with preserved ejection fraction. Methods and Results We prospectively studied 705 patients (median age, 83 years; 55% women) registered in PURSUIT‐HFpEF (Prospective Multicenter Observational Study of Patients With Heart Failure With Preserved Ejection Fraction). We investigated the association of echocardiographic PAC at discharge with the primary end point of all‐cause death or heart failure rehospitalization with a mean follow‐up of 384 days. We further tested the acceptability of the prognostic significance of PAC in a subgroup of patients (167/705 patients; median age, 81 years; 53% women) in whom PAC was assessed by right heart catheterization. The median echocardiographic PAC was 2.52 mL/mm Hg, with a quartile range of 1.78 to 3.32 mL/mm Hg. Univariable and multivariable Cox regression testing revealed that echocardiographic PAC was associated with the primary end point (unadjusted hazard ratio, 0.82; 95% CI, 0.72–0.92; P=0.001; adjusted hazard ratio, 0.86; 95% CI, 0.74–0.99; P=0.035, respectively). Univariable Cox regression testing revealed that PAC assessed by right heart catheterization (median calculated PAC, 2.82 mL/mm Hg) was also associated with the primary end point (unadjusted HR, 0.70; 95% CI, 0.52–0.91; P=0.005). Conclusions A prospective cohort study revealed that impaired PAC diagnosed with both echocardiography and right heart catheterization was associated with adverse outcomes in inpatients with heart failure with preserved ejection fraction. Registration URL: https://upload.umin.ac.jp/cgi‐open‐bin/ctr_e/ctr_view.cgi?recptno=R000024414. Unique identifier: UMIN000021831.
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Affiliation(s)
- Akito Nakagawa
- Division of Cardiovascular Medicine Amagasaki-Chuo Hospital Amagasaki Japan.,Department of Medical Informatics Osaka University Graduate School of Medicine Suita Japan
| | - Yoshio Yasumura
- Division of Cardiovascular Medicine Amagasaki-Chuo Hospital Amagasaki Japan
| | - Chikako Yoshida
- Division of Cardiovascular Medicine Amagasaki-Chuo Hospital Amagasaki Japan
| | - Takahiro Okumura
- Division of Cardiovascular Medicine Amagasaki-Chuo Hospital Amagasaki Japan
| | - Jun Tateishi
- Division of Cardiovascular Medicine Amagasaki-Chuo Hospital Amagasaki Japan
| | - Junichi Yoshida
- Division of Cardiovascular Medicine Amagasaki-Chuo Hospital Amagasaki Japan
| | - Haruhiko Abe
- Cardiovascular Division National Hospital Organization Osaka National Hospital Osaka Japan
| | - Shunsuke Tamaki
- Division of Cardiology Osaka General Medical Center Osaka Japan
| | | | | | | | - Takahisa Yamada
- Division of Cardiology Osaka General Medical Center Osaka Japan
| | - Tomoharu Dohi
- Department of Cardiovascular Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Daisaku Nakatani
- Department of Cardiovascular Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine Osaka University Graduate School of Medicine Suita Japan
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10
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Rajdev K, Lahan S, Wichman T. Role of pulmonary arterial capacitance in predicting mortality in patients with pulmonary hypertension: A systematic review and meta-analysis. Int J Cardiol 2021; 333:202-209. [PMID: 33621628 DOI: 10.1016/j.ijcard.2021.02.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/20/2021] [Accepted: 02/12/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pulmonary arterial capacitance or compliance (PAC) has been reported as an independent predictor of mortality in patients with pulmonary arterial hypertension (PAH) and pulmonary hypertension secondary to left heart disease (PH-LHD). METHODS We conducted a literature search of PubMed/Medline, Google Scholar, and Cochrane library databases from July 30th to September 4th, 2020, and identified all the relevant studies reporting mortality outcomes in patients with PAH and PH-LHD. Pooled data from these studies were used to perform a meta-analysis to identify the role of PAC in predicting all-cause mortality in this subset of patients. RESULTS Pooled data on 4997 patients from 15 individual studies showed that the mortality risk in patients with PAH and PH-LHD varies significantly per unit change in PAC either from baseline or during follow-up. A reduction in PAC per 1 ml/mmHg was associated with a 4.25 times higher risk of all-cause mortality (95% CI 1.42-12.71; p = 0.021) in PAH patients. Among patients with PH-LHD, mortality risk increased by ~30% following a unit decrease in PAC (HR, 1.29; p = 0.019), whereas an increase in PAC by 1 ml/mmHg lowered the mortality risk by 30% (HR, 0.70). CONCLUSION PAC is a strong and independent predictor of all-cause mortality in both patients with PAH and PH-LHD. A decrease in PAC by 1 ml/mmHg from baseline or during follow-up significantly increases the risk of all-cause mortality among both patients with PAH and PH-LHD. Treatment modalities targeted at PAC improvement can affect the overall survival and quality of life in such patients.
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Affiliation(s)
- Kartikeya Rajdev
- Pulmonary, Critical Care & Sleep Medicine, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Shubham Lahan
- University College of Medical Sciences, New Delhi, India
| | - Tammy Wichman
- Pulmonary, Critical Care & Sleep Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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Papolos A, Tison GH, Mayfield J, Vasti E, DeMarco T. Echocardiographic assessment of pulmonary arterial capacitance predicts mortality in pulmonary hypertension. J Cardiol 2020; 77:279-284. [PMID: 33158713 DOI: 10.1016/j.jjcc.2020.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/07/2020] [Accepted: 09/18/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pulmonary arterial capacitance (PAC) is one of the strongest predictors of clinical outcomes in patients with pulmonary hypertension (PH). We examined the value of an echocardiographic surrogate for PAC (ePAC) as a predictor of mortality in patients with PH. METHODS We performed a retrospective study of 302 patients with PH managed at a PH comprehensive care center over a cumulative follow-up time of 858 patient-years. Charts from 2004 to 2018 were reviewed to identify patients in whom a right heart catheterization (RHC) was performed within two months of an echocardiogram. Standard invasive, non-invasive, functional, and biochemical prognostic markers were extracted from the time of RHC. The primary outcome was all-cause mortality. Cox proportional hazards models were used to model the time from RHC to the primary outcome or last medical contact. RESULTS Variables associated with all-cause mortality included ePAC [standardized hazard ratio (HR) 0.68, 95% CI 0.48-0.98, p = 0.036], RHC-PAC (HR 0.68, 95% CI 0.48-0.96, p = 0.027), echocardiographic pulmonary vascular resistance (HR 1.29, 95% CI 1.05-1.60, p = 0.017), six-minute walk distance (HR 0.43, 95% CI 0.23-0.82, p = 0.01), and B-type natriuretic peptide (HR 1.29, 95% CI 1.03-1.62, p = 0.027). In multivariable-adjusted Cox analysis, ePAC predicted all-cause mortality independently of age, gender, and multiple comorbidities. There was a graded and stepwise association between low (<0.15 cm/mmHg), medium (0.15-0.25 cm/mmHg), and high (>0.25 cm/mmHg) tertiles of ePAC and all-cause mortality. CONCLUSIONS We have demonstrated that ePAC is a readily available echocardiographic marker that independently predicts mortality in PH, and have provided clinically relevant ranges by which to risk-stratify patients and predict mortality.
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Affiliation(s)
- Alexander Papolos
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Geoffrey H Tison
- Division of Cardiology, University of California, San Francisco, CA, USA; Department of Medicine, University of California, San Francisco, CA, USA; Bakar Computational Health Sciences Institute, University of California, San Francisco, CA, USA; Cardiovascular Research Institute, University of California, San Francisco, CA, USA.
| | - Jacob Mayfield
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Elena Vasti
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Teresa DeMarco
- Division of Cardiology, University of California, San Francisco, CA, USA; Department of Medicine, University of California, San Francisco, CA, USA
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12
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Guigui S, Zaidi SI, Lee JJ, Elajami T, Mihos CG, Escolar E. Relationship between compliance and pulmonary vascular resistance in pulmonary arterial hypertension. J Thorac Dis 2020; 12:2971-2976. [PMID: 32642210 PMCID: PMC7330329 DOI: 10.21037/jtd.2020.02.20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Pulmonary arterial compliance (PAC) was previously shown to be an important prognostic factor in pulmonary arterial hypertension (PAH), in addition to the conventional pulmonary vascular resistance (PVR). The product of PAC and PVR, the arterial time (RC) constant, expresses the logarithmic relationship between the hemodynamic parameters. The objective of the study was to test RC constant stability in PAH patients followed beyond 12 months after diagnosis, and to report possible RC variations in different etiologies. Methods Fourteen PAH patients followed between 2008 and 2019 were included. Type 1 PAH was defined as a mean pulmonary artery pressure (PAP) ≥25 mmHg at rest and PVR ≥3 Wood units (WU). All patients who fulfilled WHO group I PAH criteria and had undergone two right heart catheterizations at least 1 year apart were included. The recorded hemodynamic data for each patient were used to compute PVR and PAC. Results PAH etiologies included scleroderma (n=2), liver cirrhosis (n=1), hereditary hemorrhagic telangiectasia (HHT) (n=1), mixed connective tissue disease (MCTD) (n=3), and idiopathic (n=7). The RC constant remained stable for all 14 patients over a follow-up period of 3.9±2 years. Patients with MCTD displayed more favorable hemodynamics, evidenced by higher RC (12.54 vs. 10.01, P<0.01) and PAC values (2.59 vs. 1.62, P=0.02), when compared with non-MCTD PAH patients. For the entire cohort the mean PAP measured 51±14 mmHg at baseline, and 46±13 mmHg at follow-up, respectively. Conclusions The relationship between PAC and PVR remains stable in follow-up periods averaging 4 years, making compliance an important disease marker past the early stages. Patients with MCTD displayed more advantageous hemodynamic profiles when compared with patients with other PAH etiologies.
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Affiliation(s)
- Sarah Guigui
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Syed I Zaidi
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - John J Lee
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Tarec Elajami
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Christos G Mihos
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA.,Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Esteban Escolar
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA.,Pulmonary Hypertension Clinic, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
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13
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Yamashita K, Abe T, Hayata Y, Hirose T, Taniguchi S. Prognostic Value of Preoperative Pulmonary Arterial Capacitance for Patients Undergoing Aortic Valve Replacement for Severe Aortic Valve Stenosis. Circ J 2019; 83:2222-2228. [DOI: 10.1253/circj.cj-19-0316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Keigo Yamashita
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine
| | - Takehisa Abe
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine
| | - Yoshihiro Hayata
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine
| | - Tomoaki Hirose
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine
| | - Shigeki Taniguchi
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine
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14
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Lahm T, Douglas IS, Archer SL, Bogaard HJ, Chesler NC, Haddad F, Hemnes AR, Kawut SM, Kline JA, Kolb TM, Mathai SC, Mercier O, Michelakis ED, Naeije R, Tuder RM, Ventetuolo CE, Vieillard-Baron A, Voelkel NF, Vonk-Noordegraaf A, Hassoun PM. Assessment of Right Ventricular Function in the Research Setting: Knowledge Gaps and Pathways Forward. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2019; 198:e15-e43. [PMID: 30109950 DOI: 10.1164/rccm.201806-1160st] [Citation(s) in RCA: 206] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Right ventricular (RV) adaptation to acute and chronic pulmonary hypertensive syndromes is a significant determinant of short- and long-term outcomes. Although remarkable progress has been made in the understanding of RV function and failure since the meeting of the NIH Working Group on Cellular and Molecular Mechanisms of Right Heart Failure in 2005, significant gaps remain at many levels in the understanding of cellular and molecular mechanisms of RV responses to pressure and volume overload, in the validation of diagnostic modalities, and in the development of evidence-based therapies. METHODS A multidisciplinary working group of 20 international experts from the American Thoracic Society Assemblies on Pulmonary Circulation and Critical Care, as well as external content experts, reviewed the literature, identified important knowledge gaps, and provided recommendations. RESULTS This document reviews the knowledge in the field of RV failure, identifies and prioritizes the most pertinent research gaps, and provides a prioritized pathway for addressing these preclinical and clinical questions. The group identified knowledge gaps and research opportunities in three major topic areas: 1) optimizing the methodology to assess RV function in acute and chronic conditions in preclinical models, human studies, and clinical trials; 2) analyzing advanced RV hemodynamic parameters at rest and in response to exercise; and 3) deciphering the underlying molecular and pathogenic mechanisms of RV function and failure in diverse pulmonary hypertension syndromes. CONCLUSIONS This statement provides a roadmap to further advance the state of knowledge, with the ultimate goal of developing RV-targeted therapies for patients with RV failure of any etiology.
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15
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Su J, Hughes AD, Simonsen U, Nielsen-Kudsk JE, Parker KH, Howard LS, Mellemkjaer S. Impact of pulmonary endarterectomy on pulmonary arterial wave propagation and reservoir function. Am J Physiol Heart Circ Physiol 2019; 317:H505-H516. [PMID: 31225986 PMCID: PMC6703995 DOI: 10.1152/ajpheart.00181.2019] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/29/2019] [Accepted: 06/17/2019] [Indexed: 01/09/2023]
Abstract
High wave speed and large wave reflection in the pulmonary artery have previously been reported in patients with chronic thromboembolic pulmonary hypertension (CTEPH). We assessed the impact of pulmonary endarterectomy (PEA) on pulmonary arterial wave propagation and reservoir function in patients with CTEPH. Right heart catheterization was performed using a combined pressure and Doppler flow sensor-tipped guidewire to obtain simultaneous pressure and flow velocity measurements in the pulmonary artery in eight patients with CTEPH before and 3 mo after PEA. Wave intensity and reservoir-excess pressure analyses were then performed. Following PEA, mean pulmonary arterial pressure (PAPm; ∼49 vs. ∼32 mmHg), pulmonary vascular resistance (PVR; ∼11.1 vs. ∼5.1 Wood units), and wave speed (∼16.5 vs. ∼8.1 m/s), i.e., local arterial stiffness, markedly decreased. The changes in the intensity of the reflected arterial wave and wave reflection index (pre: ∼28%; post: ∼22%) were small, and patients post-PEA with and without residual pulmonary hypertension (i.e., PAPm ≥ 25 mmHg) had similar wave reflection index (∼20 vs. ∼23%). The reservoir and excess pressure decreased post-PEA, and the changes were associated with improved right ventricular afterload, function, and size. In conclusion, although PVR and arterial stiffness decreased substantially following PEA, large wave reflection persisted, even in patients without residual pulmonary hypertension, indicating lack of improvement in vascular impedance mismatch. This may continue to affect the optimal ventriculoarterial interaction, and further studies are warranted to determine whether this contributes to persistent symptoms in some patients.NEW & NOTEWORTHY We performed wave intensity analysis in the pulmonary artery in patients with chronic thromboembolic pulmonary hypertension before and 3 mo after pulmonary endarterectomy. Despite substantial reduction in pulmonary arterial pressures, vascular resistance, and arterial stiffness, large pulmonary arterial wave reflection persisted 3 mo postsurgery, even in patients without residual pulmonary hypertension, suggestive of lack of improvement in vascular impedance mismatch.
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Affiliation(s)
- Junjing Su
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Alun D Hughes
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Ulf Simonsen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | | | - Kim H Parker
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Luke S Howard
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Soren Mellemkjaer
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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16
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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.
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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.
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17
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Nagel C, Marra AM, Benjamin N, Blank N, Cittadini A, Coghlan G, Distler O, Denton CP, Egenlauf B, Fiehn C, Fischer C, Harutyunova S, Hoeper MM, Lorenz HM, Xanthouli P, Bossone E, Grünig E. Reduced Right Ventricular Output Reserve in Patients With Systemic Sclerosis and Mildly Elevated Pulmonary Artery Pressure. Arthritis Rheumatol 2019; 71:805-816. [PMID: 30615302 DOI: 10.1002/art.40814] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This prospective study was undertaken to evaluate right ventricular function and pulmonary arterial compliance (PAC; ratio of stroke volume to pulse pressure) at rest and during exercise in patients with systemic sclerosis (SSc) with normal mean pulmonary artery pressure (PAP), patients with SSc with mildly elevated mean PAP, and patients with SSc with manifest pulmonary hypertension (PH). METHODS Patients with SSc (n = 112) underwent clinical assessment and right-sided heart catheterization at rest and during exercise and were divided into 3 groups according to their resting mean PAP values: normal mean PAP (≤20 mm Hg), mildly elevated mean PAP (21-24 mm Hg), and PH (mean PAP ≥25 mm Hg). Results were compared between groups by analysis of variance followed by post hoc Student's t-test. RESULTS Compared to patients with normal mean PAP, patients with mildly elevated mean PAP had a lower 6-minute walking distance (P = 0.008), lower cardiac index (P = 0.027) and higher pulmonary vascular resistance (P = 0.0002) during exercise, and lower PAC at rest (P = 0.016) and different stages of exercise (P = 0.033 for 25W and P = 0.024 for 75W). CONCLUSION The results of this study suggest that impaired 6-minute walking distance in SSc patients with mildly elevated mean PAP might be caused by reduced PAC during exercise and reduced right ventricular output reserve, presumably due to impaired coupling between the right ventricle and the pulmonary vasculature. These findings provide further evidence of the clinical relevance of mildly elevated mean PAP in patients with SSc.
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Affiliation(s)
- Christian Nagel
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany, and Klinikum Mittelbaden Baden-Baden Balg, Baden-Baden, Germany
| | - Alberto M Marra
- SDN Scientific Institute for Research and Healthcare, Naples, Italy
| | - Nicola Benjamin
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
| | | | | | | | | | | | - Benjamin Egenlauf
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
| | | | | | - Satenik Harutyunova
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
| | | | | | - Panagiota Xanthouli
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
| | | | - Ekkehard Grünig
- Heidelberg University Hospital, German Center for Lung Research, Heidelberg, Germany
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18
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Papolos A, Fan E, Wagle RR, Foster E, Boyle AJ, Yeghiazarians Y, MacGregor JS, Grossman W, Schiller NB, Ganz P, Tison GH. Echocardiographic determination of pulmonary arterial capacitance. Int J Cardiovasc Imaging 2019; 35:1581-1586. [PMID: 30968263 DOI: 10.1007/s10554-019-01595-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 04/01/2019] [Indexed: 12/30/2022]
Abstract
A growing body of evidence has demonstrated that pulmonary arterial capacitance (PAC) is the strongest hemodynamic predictor of clinical outcomes across a wide spectrum of cardiovascular disease, including pulmonary hypertension and heart failure. We hypothesized that a ratio of right ventricular stroke volume (RVOT VTI) to the associated peak arterial systolic pressure (PASP) could function as a reliable non-invasive surrogate for PAC. We performed a prospective study of patients undergoing simultaneous transthoracic echocardiography and right heart catheterization (RHC) for various clinical indications. Measurements of the RVOT VTI/PASP ratio from echocardiographic measurements were compared against PAC calculated from RHC measurements. Correlation coefficients and Bland-Altman analysis compared the RVOT VTI/PASP ratio with PAC. Forty-five subjects were enrolled, 38% were female and mean age was 54 years (SD 13 years). The reason for referral to RHC was most commonly post-heart transplant surveillance (40%), followed by heart failure (22%), and pulmonary hypertension (18%). Pre-capillary pulmonary hypertension was present in 18%, isolated post-capillary pulmonary hypertension was present in 13%, and combined pre-and post-capillary pulmonary hypertension was present in 29%. The RVOT VTI/PASP ratio was obtainable in the majority of patients (78%), and Pearson's correlation demonstrated moderately-strong association between PAC and the RVOT VTI/PASP ratio, r = 0.75 (P < 0.001). Bland-Altman analysis demonstrated good agreement between measurements without suggestion of systematic bias and a mean difference in standardized units of - 0.133. In a diverse population of patients and hemodynamic profiles, we validated that the ratio of RVOT VTI/PASP to be a reliably-obtained non-invasive marker associated with PAC.
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Affiliation(s)
- Alexander Papolos
- Division of Cardiology, University of California, San Francisco, 555 Mission Bay Blvd South, Box 3120, San Francisco, CA, 94158, USA
| | - Eugene Fan
- Division of Cardiology, University of California, San Francisco, 555 Mission Bay Blvd South, Box 3120, San Francisco, CA, 94158, USA
| | | | - Elyse Foster
- Division of Cardiology, University of California, San Francisco, 555 Mission Bay Blvd South, Box 3120, San Francisco, CA, 94158, USA
| | - Andrew J Boyle
- Division of Cardiology, The University of Newcastle, Callaghan, Australia
| | - Yerem Yeghiazarians
- Division of Cardiology, University of California, San Francisco, 555 Mission Bay Blvd South, Box 3120, San Francisco, CA, 94158, USA
| | - John S MacGregor
- Division of Cardiology, University of California, San Francisco, 555 Mission Bay Blvd South, Box 3120, San Francisco, CA, 94158, USA
| | - William Grossman
- Division of Cardiology, University of California, San Francisco, 555 Mission Bay Blvd South, Box 3120, San Francisco, CA, 94158, USA
| | - Nelson B Schiller
- Division of Cardiology, University of California, San Francisco, 555 Mission Bay Blvd South, Box 3120, San Francisco, CA, 94158, USA
| | - Peter Ganz
- Division of Cardiology, University of California, San Francisco, 555 Mission Bay Blvd South, Box 3120, San Francisco, CA, 94158, USA
| | - Geoffrey H Tison
- Division of Cardiology, University of California, San Francisco, 555 Mission Bay Blvd South, Box 3120, San Francisco, CA, 94158, USA.
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19
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Hur DJ, Sugeng L. Non-invasive Multimodality Cardiovascular Imaging of the Right Heart and Pulmonary Circulation in Pulmonary Hypertension. Front Cardiovasc Med 2019; 6:24. [PMID: 30931315 PMCID: PMC6427926 DOI: 10.3389/fcvm.2019.00024] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 02/20/2019] [Indexed: 12/13/2022] Open
Abstract
Pulmonary hypertension (PH) is defined as resting mean pulmonary arterial pressure (mPAP) ≥25 millimeters of mercury (mmHg) via right heart (RH) catheterization (RHC), where increased afterload in the pulmonary arterial vasculature leads to alterations in RH structure and function. Mortality rates have remained high despite therapy, however non-invasive imaging holds the potential to expedite diagnosis and lead to earlier initiation of treatment, with the hope of improving prognosis. While historically the right ventricle (RV) had been considered a passive chamber with minimal role in the overall function of the heart, in recent years in the evaluation of PH and RH failure the anatomical and functional assessment of the RV has received increased attention regarding its performance and its relationship to other structures in the RH-pulmonary circulation. Today, the RV is the key determinant of patient survival. This review provides an overview and summary of non-invasive imaging methods to assess RV structure, function, flow, and tissue characterization in the setting of imaging's contribution to the diagnostic, severity stratification, prognostic risk, response of treatment management, and disease surveillance implications of PH's impact on RH dysfunction and clinical RH failure.
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Affiliation(s)
- David J Hur
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States.,Division of Cardiology, Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States
| | - Lissa Sugeng
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States.,Echocardiography Laboratory, Yale New Haven Hospital, New Haven, CT, United States
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20
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Bhattacharya S, Sen S, Levy PT, Rios DR. Comprehensive Evaluation of Right Heart Performance and Pulmonary Hemodynamics in Neonatal Pulmonary Hypertension : Evaluation of cardiopulmonary performance in neonatal pulmonary hypertension. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:10. [PMID: 30767138 DOI: 10.1007/s11936-019-0713-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Pulmonary hypertension is characterized by an elevation of pulmonary artery pressures and prolonged exposure of the right ventricle to high afterload that collectively contribute to morbidity and mortality in both the term and preterm infants. This review summarizes the pathogenesis, etiologies, and hemodynamic profiles of the conditions that result in pulmonary hypertension in neonates. We explore the application of echocardiographic techniques for the assessment of right ventricular performance and pulmonary hemodynamics that enhance and guide the diagnosis and management strategies in neonates. RECENT FINDINGS Clinical assessments based on the determinants of mean pulmonary artery pressures (pulmonary vascular resistance, pulmonary blood flow, and pulmonary capillary wedge pressure) provide a physiologic approach in determining the acute and chronic etiologies of pulmonary hypertension in neonates. In addition, advances in neonatal echocardiography now afford the capability to obtain quantitative information that often precedes the qualitative information acquired by conventional methods and also provide sensitive markers of right ventricle performance for prognostic information based on the determinants of mean pulmonary artery pressures. Neonatal pulmonary hypertension represents a physiologic spectrum that accounts for the variance in clinical presentation and response to therapies. Physiology-based approaches to etiological identification, coupled with the emerging echocardiographic methods for the assessment of pulmonary hypertension in neonates will likely help to identify cardiovascular compromise earlier, guide therapeutic intervention, monitor therapeutic effectiveness, and improve overall outcome.
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Affiliation(s)
- Soume Bhattacharya
- Division of Neonatology, Department of Paediatrics, Western University, London, ON, Canada
| | - Shawn Sen
- Divisions of Neonatology and Pediatric Cardiology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Philip T Levy
- Division of Newborn Medicine, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Hunnewell 436, Boston, MA, 02115, USA.
| | - Danielle R Rios
- Section of Neonatology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
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21
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Vonk Noordegraaf A, Chin KM, Haddad F, Hassoun PM, Hemnes AR, Hopkins SR, Kawut SM, Langleben D, Lumens J, Naeije R. Pathophysiology of the right ventricle and of the pulmonary circulation in pulmonary hypertension: an update. Eur Respir J 2019; 53:13993003.01900-2018. [PMID: 30545976 PMCID: PMC6351344 DOI: 10.1183/13993003.01900-2018] [Citation(s) in RCA: 292] [Impact Index Per Article: 58.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/09/2018] [Indexed: 01/07/2023]
Abstract
The function of the right ventricle determines the fate of patients with pulmonary hypertension. Since right heart failure is the consequence of increased afterload, a full physiological description of the cardiopulmonary unit consisting of both the right ventricle and pulmonary vascular system is required to interpret clinical data correctly. Here, we provide such a description of the unit and its components, including the functional interactions between the right ventricle and its load. This physiological description is used to provide a framework for the interpretation of right heart catheterisation data as well as imaging data of the right ventricle obtained by echocardiography or magnetic resonance imaging. Finally, an update is provided on the latest insights in the pathobiology of right ventricular failure, including key pathways of molecular adaptation of the pressure overloaded right ventricle. Based on these outcomes, future directions for research are proposed. State of the art and research perspectives in pathophysiology of the right ventricle and of the pulmonary circulation in pulmonary hypertension with theoretical and practical aspectshttp://ow.ly/18v830mgLiP
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Affiliation(s)
- Anton Vonk Noordegraaf
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Kelly Marie Chin
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - François Haddad
- Division of Cardiovascular Medicine, Stanford University and Stanford Cardiovascular Institute, Palo Alto, CA, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Steven Mark Kawut
- Penn Cardiovascular Institute, Dept of Medicine, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David Langleben
- Center for Pulmonary Vascular Disease, Cardiology Division, Jewish General Hospital and McGill University, Montreal, QC, Canada
| | - Joost Lumens
- Maastricht University Medical Center, CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands.,Université de Bordeaux, LIRYC (L'Institut de Rythmologie et Modélisation Cardiaque), Bordeaux, France
| | - Robert Naeije
- Dept of Cardiology, Erasme University Hospital, Brussels, Belgium.,Laboratory of Cardiorespiratory Exercise Physiology, Faculty of Motor Sciences, Université Libre de Bruxelles, Brussels, Belgium
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22
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Dieffenbach PB, Maracle M, Tschumperlin DJ, Fredenburgh LE. Mechanobiological Feedback in Pulmonary Vascular Disease. Front Physiol 2018; 9:951. [PMID: 30090065 PMCID: PMC6068271 DOI: 10.3389/fphys.2018.00951] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 06/28/2018] [Indexed: 01/06/2023] Open
Abstract
Vascular stiffening in the pulmonary arterial bed is increasingly recognized as an early disease marker and contributor to right ventricular workload in pulmonary hypertension. Changes in pulmonary artery stiffness throughout the pulmonary vascular tree lead to physiologic alterations in pressure and flow characteristics that may contribute to disease progression. These findings have led to a greater focus on the potential contributions of extracellular matrix remodeling and mechanical signaling to pulmonary hypertension pathogenesis. Several recent studies have demonstrated that the cellular response to vascular stiffness includes upregulation of signaling pathways that precipitate further vascular remodeling, a process known as mechanobiological feedback. The extracellular matrix modifiers, mechanosensors, and mechanotransducers responsible for this process have become increasingly well-recognized. In this review, we discuss the impact of vascular stiffening on pulmonary hypertension morbidity and mortality, evidence in favor of mechanobiological feedback in pulmonary hypertension pathogenesis, and the major contributors to mechanical signaling in the pulmonary vasculature.
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Affiliation(s)
- Paul B Dieffenbach
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Marcy Maracle
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Daniel J Tschumperlin
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine and Science, Rochester, MN, United States
| | - Laura E Fredenburgh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States
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23
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Kasprzak JD, Huttin O, Wierzbowska-Drabik K, Selton-Suty C. Imaging the Right Heart-Pulmonary Circulation Unit. Heart Fail Clin 2018; 14:361-376. [DOI: 10.1016/j.hfc.2018.03.003] [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] [Indexed: 10/28/2022]
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24
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Nagiub M, Klein J, Gullquist S. Echocardiography derived pulmonary artery capacitance and right ventricular outflow velocity time integral on first day of life can predict survival in congenital diaphragmatic hernia. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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25
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Prognostic relevance of elevated pulmonary arterial pressure assessed non-invasively: Analysis in a large patient cohort with invasive measurements in near temporal proximity. PLoS One 2018; 13:e0191206. [PMID: 29351312 PMCID: PMC5774714 DOI: 10.1371/journal.pone.0191206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 12/30/2017] [Indexed: 12/13/2022] Open
Abstract
Background The clinical relevance of non-invasively derived pulmonary arterial pressure (PAP) by Doppler echocardiography (DE) has been questioned in the past. However, transthoracic echocardiography is used as a cornerstone examination for patients with dyspnea and suspected pulmonary hypertension (PH). This study aimed to evaluate the prognostic value of non-invasive assessed PAP in a large population of patients with known or suspected cardiopulmonary disease. Methods The analyses are based on data of patients of a tertiary cardiology center that received right heart catheterization (RHC) as well as non-invasively assessed PAP by DE within five days, and includes serological and clinical parameters in a retrospective follow-up for up to eight years. Results Of 1,237 patients, clinical follow-up was possible in 1,038 patients who were included in the statistical analysis. The mean-follow up time was 1,002 days. The composite endpoint of heart transplantation (HTx) or death occurred in n = 308 patients. Elevated PAP measured non-invasively as well as invasively had significant prognostic impact (hazard ratio (HR) 2.32; 95% confidence interval (CI) 1.78–3.04; χ2 = 37.9; p<0.001 versus HR 2.84; 95%CI 2.11–3.82; χ2 = 51.9; p<0.001, respectively). By multivariate analysis, NYHA functional class, N-terminal pro-brain natriuretic peptide, cardiac troponin T, left ventricular ejection fraction, and right ventricular dysfunction remained independently predictive. Incremental prognostic information in a multimodal approach was highly relevant. Conclusions In this comprehensive study, elevated pulmonary arterial pressure measured by DE offers similar prognostic information on survival or need for HTx as right heart catheterization. Furthermore, the addition of functional capacity and serological biomarkers delivered incremental prognostic information.
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Pulmonary Arterial Compliance Improves Rapidly After Left Ventricular Assist Device Implantation. ASAIO J 2018; 63:139-143. [PMID: 27831997 DOI: 10.1097/mat.0000000000000467] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Pulmonary artery compliance (PAC) contributes to right ventricular (RV) afterload, is decreased in the setting of increased left ventricular (LV) filling pressures, and may be an important component of World Health Organization (WHO) group II pulmonary hypertension (PH). Left ventricular assist device (LVAD) implantation can rapidly change LV filling, but its relationship with PAC is unknown. Right heart catheterization was performed preoperatively, postoperatively (between 48 and 72 hours), and >30 days post-LVAD implantation in a cohort of 64 patients with end-stage systolic heart failure. Within 72 hours, LVAD implantation was associated with an increase in PAC (2.0-3.7 ml/mm Hg, p < 0.0001), a decrease in pulmonary vascular resistance (3.5-1.7 Wood units, p < 0.0001). Pulmonary arterial compliance did not increase further at the >30 post-LVAD time point (3.7 ± 1.7 to 3.6 ± 0.44 ml/mm Hg, p = 0.44). Pulmonary artery compliance improves rapidly after LVAD implantation. This suggests that more permanent changes in the pulmonary vascular bed may not be responsible for the abnormal PAC observed in WHO group II PH.
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27
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Wright LM, Dwyer N, Celermajer D, Kritharides L, Marwick TH. Follow-Up of Pulmonary Hypertension With Echocardiography. JACC Cardiovasc Imaging 2017; 9:733-46. [PMID: 27282440 DOI: 10.1016/j.jcmg.2016.02.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/08/2016] [Accepted: 02/11/2016] [Indexed: 10/21/2022]
Abstract
Individual patient response to effective therapies for pulmonary hypertension (PAH) is variable and difficult to quantify. Consequently, management decisions regarding initiation and continuation of therapy are highly dependent on the results of investigations. Registry data show that changes in cardiac index, mean right atrial pressure, and mean pulmonary artery pressure have the greatest influence on survival. It is recognized that pulmonary artery pressure (PASP) responses to PAH-specific drugs are heterogeneous. However, follow-up testing is strongly focused on assessing changes in PASP and functional status (6-min walk). The goals of therapy, which should be highlighted in follow-up imaging, include not only reduction of PASP, decrease in pulmonary vascular resistance, and improvements in right ventricular function, cardiac output, and tricuspid regurgitation. This paper reviews the echocardiographic follow-up of pulmonary hypertension, and especially focuses on right ventricular function-a major determinant of outcome, for which reliable echocardiographic assessment has become more feasible.
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Affiliation(s)
- Leah M Wright
- Menzies Institute for Medical Research, Hobart, Australia; Royal Hobart Hospital, Hobart, Australia; Baker-IDI Heart and Diabetes Institute, Melbourne, Australia
| | | | | | | | - Thomas H Marwick
- Menzies Institute for Medical Research, Hobart, Australia; Royal Hobart Hospital, Hobart, Australia; Baker-IDI Heart and Diabetes Institute, Melbourne, Australia.
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28
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Metas en hipertensión pulmonar. REVISTA COLOMBIANA DE CARDIOLOGÍA 2017. [DOI: 10.1016/j.rccar.2017.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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29
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Dieffenbach PB, Haeger CM, Coronata AMF, Choi KM, Varelas X, Tschumperlin DJ, Fredenburgh LE. Arterial stiffness induces remodeling phenotypes in pulmonary artery smooth muscle cells via YAP/TAZ-mediated repression of cyclooxygenase-2. Am J Physiol Lung Cell Mol Physiol 2017; 313:L628-L647. [PMID: 28642262 PMCID: PMC5625262 DOI: 10.1152/ajplung.00173.2017] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 06/07/2017] [Accepted: 06/11/2017] [Indexed: 12/20/2022] Open
Abstract
Pulmonary arterial stiffness is an independent risk factor for mortality in pulmonary hypertension (PH) and plays a critical role in PH pathophysiology. Our laboratory has recently demonstrated arterial stiffening early in experimental PH, along with evidence for a mechanobiological feedback loop by which arterial stiffening promotes further cellular remodeling behaviors (Liu F, Haeger CM, Dieffenbach PB, Sicard D, Chrobak I, Coronata AM, Suárez Velandia MM, Vitali S, Colas RA, Norris PC, Marinković A, Liu X, Ma J, Rose CD, Lee SJ, Comhair SA, Erzurum SC, McDonald JD, Serhan CN, Walsh SR, Tschumperlin DJ, Fredenburgh LE. JCI Insight 1: e86987, 2016). Cyclooxygenase-2 (COX-2) and prostaglandin signaling have been implicated in stiffness-mediated regulation, with prostaglandin activity inversely correlated to matrix stiffness and remodeling behaviors in vitro, as well as to disease progression in rodent PH models. The mechanism by which mechanical signaling translates to reduced COX-2 activity in pulmonary vascular cells is unknown. The present work investigated the transcriptional regulators Yes-associated protein (YAP) and WW domain-containing transcription regulator 1 (WWTR1, a.k.a., TAZ), which are known drivers of downstream mechanical signaling, in mediating stiffness-induced changes in COX-2 and prostaglandin activity in pulmonary artery smooth muscle cells (PASMCs). We found that YAP/TAZ activity is increased in PAH PASMCs and experimental PH and is necessary for the development of stiffness-dependent remodeling phenotypes. Knockdown of YAP and TAZ markedly induces COX-2 expression and downstream prostaglandin production by approximately threefold, whereas overexpression of YAP or TAZ reduces COX-2 expression and prostaglandin production to near undetectable levels. Together, our findings demonstrate a stiffness-dependent YAP/TAZ-mediated positive feedback loop that drives remodeling phenotypes in PASMCs via reduced COX-2 and prostaglandin activity. The ability to interrupt this critical mechanobiological feedback loop and enhance local prostaglandin activity via manipulation of YAP/TAZ signaling presents a highly attractive novel strategy for the treatment of PH.
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Affiliation(s)
- Paul B Dieffenbach
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Christina Mallarino Haeger
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Anna Maria F Coronata
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kyoung Moo Choi
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; and
| | - Xaralabos Varelas
- Department of Biochemistry, Boston University School of Medicine, Boston, Massachusetts
| | - Daniel J Tschumperlin
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota; and
| | - Laura E Fredenburgh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts;
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30
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Venkatachalam S, Wu G, Ahmad M. Echocardiographic assessment of the right ventricle in the current era: Application in clinical practice. Echocardiography 2017; 34:1930-1947. [PMID: 28833543 DOI: 10.1111/echo.13651] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The right ventricle has unique structural and functional characteristics. It is now well recognized that the so-called forgotten ventricle is a key player in cardiovascular physiology. Furthermore, there is accumulating evidence that demonstrates right ventricular dysfunction as an important marker of morbidity and mortality in several commonly encountered clinical situations such as heart failure, pulmonary hypertension, pulmonary embolism, right ventricular myocardial infarction, and adult congenital heart disease. In contrast to the left ventricle, echocardiographic assessment of right ventricular function is more challenging as volume estimations are not possible without the use of three-dimensional (3D) echocardiography. Guidelines on chamber quantification provide a standardized approach to assessment of the right ventricle. The technique and limitations of each of the parameters for RV size and function need to be fully understood. In this era of multimodality imaging, echocardiography continues to remain a useful tool for the initial assessment and follow-up of patients with right heart pathology. Several novel approaches such as 3D and strain imaging of the right ventricle have expanded the usefulness of this indispensable modality.
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Affiliation(s)
- Sridhar Venkatachalam
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Geru Wu
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Masood Ahmad
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
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31
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Pulmonary Arterial Compliance in Acute Respiratory Distress Syndrome: Clinical Determinants and Association With Outcome From the Fluid and Catheter Treatment Trial Cohort. Crit Care Med 2017; 45:422-429. [PMID: 27941369 DOI: 10.1097/ccm.0000000000002186] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Pulmonary vascular dysfunction is associated with adverse prognosis in patients with the acute respiratory distress syndrome; however, the prognostic impact of pulmonary arterial compliance in acute respiratory distress syndrome is not established. DESIGN, SETTING, PATIENTS We performed a retrospective analysis of 363 subjects with acute respiratory distress syndrome who had complete baseline right heart catheterization data from the Fluid and Catheter Treatment Trial to test whether pulmonary arterial compliance at baseline and over the course of treatment predicted mortality. MAIN RESULTS Baseline pulmonary arterial compliance (hazard ratio, 1.18 per interquartile range of 1/pulmonary arterial compliance; 95% CI, 1.02-1.37; p = 0.03) and pulmonary vascular resistance (hazard ratio, 1.28 per interquartile range; 95% CI, 1.07-1.53; p = 0.006) both modestly predicted 60-day mortality. Baseline pulmonary arterial compliance remained predictive of mortality when pulmonary vascular resistance was in the normal range (p = 0.02). Between day 0 and day 3, pulmonary arterial compliance increased in acute respiratory distress syndrome survivors and remained unchanged in nonsurvivors, whereas pulmonary vascular resistance did not change in either group. The resistance-compliance product (resistance-compliance time) increased in survivors compared with nonsurvivors, suggesting improvements in right ventricular load. CONCLUSIONS Baseline measures of pulmonary arterial compliance and pulmonary vascular resistance predict mortality in acute respiratory distress syndrome, and pulmonary arterial compliance remains predictive even when pulmonary vascular resistance is normal. Pulmonary arterial compliance and right ventricular load improve over time in acute respiratory distress syndrome survivors. Future studies should assess the impact of right ventricular protective acute respiratory distress syndrome treatment on right ventricular afterload and outcome.
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32
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Medrek SK, Kloefkorn C, Nguyen DTM, Graviss EA, Frost AE, Safdar Z. Longitudinal change in pulmonary arterial capacitance as an indicator of prognosis and response to therapy and in pulmonary arterial hypertension. Pulm Circ 2017; 7:399-408. [PMID: 28597758 PMCID: PMC5467926 DOI: 10.1177/2045893217698715] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a chronic progressive disease that leads to right heart failure and death. Pulmonary arterial capacitance (PAC), defined as stroke volume divided by the pulmonary pulse pressure, has been identified as a prognostic factor in PAH. The impact of changes in PAC over time, however, is unclear. We evaluated changes in PAC over time to determine if such changes predicted transplant-free survival. A single-center retrospective study of consecutive group 1 PAH patients who had two or more right heart catheterizations (RHC) between January 2007 and June 2016 was undertaken. Hemodynamic data, clinical data, and outcomes were collected. Univariate and multivariate Cox proportional-hazards modelling to identify the contribution of risk factors for a composite outcome of death or lung transplantation was done. Mixed-effects logistic regression was performed to investigate the association between the change in PAC value over time and the composite outcome. A P value < 0.05 was considered significant. In total, 109 consecutive patients with a total of 300 RHC data were identified. PAC correlated inversely with functional status ( P < 0.001) and inversely with pulmonary vascular resistance ( P < 0.001). PAC values increased with the addition of new PAH-specific medications. Mixed effects logistic regression modeling using longitudinal data showed that a decrease in PAC over the study period was associated with increased mortality and transplantation (adjusted P = 0.039) over the study period. Change in PAC was a better predictor of outcome over the study period than baseline PAC or changes in other hemodynamic or clinical parameters. Decreases in PAC were predictive of increased mortality or transplantation in patients with group 1 PAH. There was a trend towards increased PAC in response to the addition of a PAH-specific medication. Our data support the use of PAC as a therapeutic target in PAH.
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Affiliation(s)
- Sarah K Medrek
- 1 Department of Pulmonary, Sleep, and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Chad Kloefkorn
- 1 Department of Pulmonary, Sleep, and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Duc T M Nguyen
- 2 Institute for Academic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Edward A Graviss
- 2 Institute for Academic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Adaani E Frost
- 2 Institute for Academic Medicine, Houston Methodist Hospital, Houston, TX, USA.,3 Weill Cornell College of Medicine, New York, NY, USA
| | - Zeenat Safdar
- 2 Institute for Academic Medicine, Houston Methodist Hospital, Houston, TX, USA.,3 Weill Cornell College of Medicine, New York, NY, USA
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33
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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.
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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
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34
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Pulmonary Arterial Capacitance Index Is a Strong Predictor for Adverse Outcome in Children with Idiopathic and Heritable Pulmonary Arterial Hypertension. J Pediatr 2017; 180:75-79.e2. [PMID: 27810156 DOI: 10.1016/j.jpeds.2016.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 08/03/2016] [Accepted: 10/03/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate the clinical utility of pulmonary artery capacitance index (PACi) in the assessment of disease severity and prognostic value in children with idiopathic and heritable pulmonary arterial hypertension (PAH). STUDY DESIGN PACi is defined as the ratio of stroke volume index over pulmonary pulse pressure. A retrospective study was performed to compare PACi, brain natriuretic peptide (BNP), 6-minute walk distance, New York Heart association (NYHA) functional class, and adverse outcomes (hospitalization due to heart failure, lung transplantation, and cardiac mortality) in 72 Japanese children (10 ± 3.6 years) with idiopathic and heritable PAH. RESULTS PACi had significant correlations with pulmonary vascular resistance index (r =-0.73, P < .0001), BNP levels (r = -0.40, P = .0008), and 6-minute walk distance (r = 0.57, P < .05). Statistically significant differences in PACi were observed between NYHA functional class II vs combined III and IV (median; 1.1 vs 0.6 mL/mm Hg/m2, respectively, P < .05). There were 25 of 72 (35%) children who had an adverse event including initiation of hospitalization due to heart failure, lung transplantation, and death. Cumulative event-free survival rate was significantly lower when PACi was <0.85 mL/mm Hg/m2 (log-rank test, P < .0001). CONCLUSIONS PACi correlated with BNP and NYHA functional class and may serve as a strong prognostic marker in children with idiopathic and heritable PAH.
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Abstract
The normal pulmonary circulation is a low-pressure, high-compliance system. Pulmonary arterial compliance decreases in the presence of pulmonary hypertension because of increased extracellular matrix/collagen deposition in the pulmonary arteries. Loss of pulmonary arterial compliance has been consistently shown to be a predictor of increased mortality in patients with pulmonary hypertension, even more so than pulmonary vascular resistance in some studies. Decreased pulmonary arterial compliance causes premature reflection of waves from the distal pulmonary vasculature, leading to increased pulsatile right ventricular afterload and eventually right ventricular failure. Evidence suggests that decreased pulmonary arterial compliance is a cause rather than a consequence of distal small vessel proliferative vasculopathy. Pulmonary arterial compliance decreases early in the disease process even when pulmonary artery pressure and pulmonary vascular resistance are normal, potentially enabling early diagnosis of pulmonary vascular disease, especially in high-risk populations. With the recognition of the prognostic importance of pulmonary arterial compliance, its impact on right ventricular function, and its contributory role in the development and progression of distal small-vessel proliferative vasculopathy, pulmonary arterial compliance is an attractive target for the treatment of pulmonary hypertension.
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Claessen G, La Gerche A. Stressing the right ventricular-pulmonary vascular unit: beyond pulmonary vascular resistance. Heart 2016; 103:404-406. [PMID: 27729387 DOI: 10.1136/heartjnl-2016-310360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Guido Claessen
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,University Hospitals Leuven, Leuven, Belgium
| | - Andre La Gerche
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Baker IDI Heart and Diabetes Institute, Melbourne, Australia
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Weir-McCall JR, Kamalasanan A, Cassidy DB, Struthers AD, Lipworth BJ, Houston JG. Assessment of proximal pulmonary arterial stiffness using magnetic resonance imaging: effects of technique, age and exercise. BMJ Open Respir Res 2016; 3:e000149. [PMID: 27843548 PMCID: PMC5073626 DOI: 10.1136/bmjresp-2016-000149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 09/16/2016] [Accepted: 09/19/2016] [Indexed: 01/09/2023] Open
Abstract
Introduction To compare the reproducibility of pulmonary pulse wave velocity (PWV) techniques, and the effects of age and exercise on these. Methods 10 young healthy volunteers (YHV) and 20 older healthy volunteers (OHV) with no cardiac or lung condition were recruited. High temporal resolution phase contrast sequences were performed through the main pulmonary arteries (MPAs), right pulmonary arteries (RPAs) and left pulmonary arteries (LPAs), while high spatial resolution sequences were obtained through the MPA. YHV underwent 2 MRIs 6 months apart with the sequences repeated during exercise. OHV underwent an MRI scan with on-table repetition. PWV was calculated using the transit time (TT) and flow area techniques (QA). 3 methods for calculating QA PWV were compared. Results PWV did not differ between the two age groups (YHV 2.4±0.3/ms, OHV 2.9±0.2/ms, p=0.1). Using a high temporal resolution sequence through the RPA using the QA accounting for wave reflections yielded consistently better within-scan, interscan, intraobserver and interobserver reproducibility. Exercise did not result in a change in either TT PWV (mean (95% CI) of the differences: −0.42 (−1.2 to 0.4), p=0.24) or QA PWV (mean (95% CI) of the differences: 0.10 (−0.5 to 0.9), p=0.49) despite a significant rise in heart rate (65±2 to 87±3, p<0.0001), blood pressure (113/68 to 130/84, p<0.0001) and cardiac output (5.4±0.4 to 6.7±0.6 L/min, p=0.004). Conclusions QA PWV performed through the RPA using a high temporal resolution sequence accounting for wave reflections yields the most reproducible measurements of pulmonary PWV.
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Affiliation(s)
- Jonathan R Weir-McCall
- Division of Cardiovascular and Diabetes Medicine , Medical Research Institute, University of Dundee , Dundee , UK
| | - Anu Kamalasanan
- Department of Clinical Radiology , Ninewells Hospital and Medical School , Dundee , UK
| | - Deidre B Cassidy
- Division of Cardiovascular and Diabetes Medicine , Medical Research Institute, University of Dundee , Dundee , UK
| | - Allan D Struthers
- Division of Cardiovascular and Diabetes Medicine , Medical Research Institute, University of Dundee , Dundee , UK
| | - Brian J Lipworth
- Scottish Centre for Respiratory Research, Medical Research Institute, University of Dundee , Dundee , UK
| | - J Graeme Houston
- Division of Cardiovascular and Diabetes Medicine , Medical Research Institute, University of Dundee , Dundee , UK
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Hayabuchi Y, Ono A, Homma Y, Kagami S. Noninvasive assessment of pulmonary arterial capacitance by pulmonary annular motion velocity in children with ventricular septal defect. Cardiovasc Ultrasound 2016; 14:38. [PMID: 27604100 PMCID: PMC5015327 DOI: 10.1186/s12947-016-0081-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 08/31/2016] [Indexed: 11/17/2022] Open
Abstract
Background We hypothesized that longitudinal pulmonary arterial deformation during the cardiac cycle reflects pulmonary arterial capacitance. To examine this hypothesis, we assessed whether tissue Doppler-derived pulmonary annular motion could serve as a novel way to evaluate pulmonary arterial capacitance in pediatric patients with ventricular septal defect (VSD). Methods In this prospective study, pulmonary annular velocity was measured in children (age, 6 months–5 years) with a preoperative VSD (VSD group, n = 35) and age-matched healthy children (Control group, n = 23). Pulmonary artery capacitance was calculated by two methods. Systolic pulmonary arterial capacitance (sPAC) was expressed as the stroke volume/pulmonary arterial pulse pressure. Diastolic pulmonary arterial capacitance (dPAC) was determined according to a two-element windkessel model of the pulmonary arterial diastolic pressure profile. Results Pulmonary annular velocity waveforms comprised systolic bimodal (s1′ and s2′) and diastolic e’ and a’ waves in all participants. The peak velocities of s1′, s2′, and e’ were significantly lower in the VSD group than in the Control group. On multiple regression analysis, sPAC was an independent variable affecting the peak velocities of the s1′, s2′, and e’ waves (β = 0.41, 0.62, and 0.35, respectively). The dPAC affected the s1′ wave peak velocity (β = 0.34). The time durations of the s1′ and e’ waves were independently determined by the sPAC (β = 0.49 and 0.27). Conclusion Pulmonary annular motion velocity evaluated using tissue Doppler is a promising method of assessing pulmonary arterial capacitance in children with VSD. Electronic supplementary material The online version of this article (doi:10.1186/s12947-016-0081-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yasunobu Hayabuchi
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima, 770-8305, Japan.
| | - Akemi Ono
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima, 770-8305, Japan
| | - Yukako Homma
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima, 770-8305, Japan
| | - Shoji Kagami
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima, 770-8305, Japan
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Abstract
PURPOSE OF REVIEW Pulmonary hypertension is a progressive disease of the pulmonary vasculature characterized by increased vascular resistance and pressure overload of the right ventricle. This review aims to describe the diagnostic and prognostic role of echocardiography in pulmonary hypertension with particular consideration of relative strengths, weaknesses and new advances. RECENT FINDINGS Although right heart catheterization (RHC) remains the gold standard, echocardiography represents an accessible and feasible real-world tool for screening, differential diagnostic, follow-up assessments and risk stratification in pulmonary hypertension. In the context of clinical scenario and multimaging approach, echocardiography provides accurate measurements of pulmonary haemodynamics, either at rest and/or during exercise, and is particularly useful in ruling out secondary causes of pulmonary hypertension and/or detecting preclinical stages. The use of advanced noninvasive imaging techniques may provide additional information in assessing right heart structure and function. SUMMARY Advances in echocardiography and the multimodality imaging approach continue to provide new understandings and opportunities for the study of the right heart-pulmonary circulation unit in pulmonary hypertension.
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Kane GC, Sachdev A, Villarraga HR, Ammash NM, Oh JK, McGoon MD, Pellikka PA, McCully RB. Impact of age on pulmonary artery systolic pressures at rest and with exercise. Echo Res Pract 2016; 3:53-61. [PMID: 27343212 PMCID: PMC4989097 DOI: 10.1530/erp-16-0006] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 05/18/2016] [Indexed: 12/14/2022] Open
Abstract
AIM It is not well known if advancing age influences normal rest or exercise pulmonary artery pressures. The purpose of the study was to evaluate the association of increasing age with measurements of pulmonary artery systolic pressure at rest and with exercise. SUBJECTS AND METHODS A total of 467 adults without cardiopulmonary disease and normal exercise capacity (age range: 18-85 years) underwent symptom-limited treadmill exercise testing with Doppler measurement of rest and exercise pulmonary artery systolic pressure. RESULTS There was a progressive increase in rest and exercise pulmonary artery pressures with increasing age. Pulmonary artery systolic pressures at rest and with exercise were 25±5mmHg and 33±9mmHg, respectively, in those <40 years, and 30±5mmHg and 41±12mmHg, respectively, in those ≥70 years. While elevated left-sided cardiac filling pressures were excluded by protocol design, markers of arterial stiffness associated with the age-dependent effects on pulmonary pressures. CONCLUSION These data demonstrate that in echocardiographically normal adults, pulmonary artery systolic pressure increases with advancing age. This increase is seen at rest and with exercise. These increases in pulmonary pressure occur in association with decreasing transpulmonary flow and increases in systemic pulse pressure, suggesting that age-associated blood vessel stiffening may contribute to these differences in pulmonary artery systolic pressure.
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Affiliation(s)
- Garvan C Kane
- Echocardiography Laboratory, Mayo Clinic, Rochester, Minnesota, USA Pulmonary Hypertension Clinic, Department Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Arun Sachdev
- Echocardiography Laboratory, Mayo Clinic, Rochester, Minnesota, USA Division of Cardiovascular Diseases, Bangkok Heart Hospital, Bangkok, Thailand
| | | | - Naser M Ammash
- Echocardiography Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Jae K Oh
- Echocardiography Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael D McGoon
- Pulmonary Hypertension Clinic, Department Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Robert B McCully
- Echocardiography Laboratory, Mayo Clinic, Rochester, Minnesota, USA Pulmonary Hypertension Clinic, Department Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
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Liu F, Haeger CM, Dieffenbach PB, Sicard D, Chrobak I, Coronata AMF, Suárez Velandia MM, Vitali S, Colas RA, Norris PC, Marinković A, Liu X, Ma J, Rose CD, Lee SJ, Comhair SAA, Erzurum SC, McDonald JD, Serhan CN, Walsh SR, Tschumperlin DJ, Fredenburgh LE. Distal vessel stiffening is an early and pivotal mechanobiological regulator of vascular remodeling and pulmonary hypertension. JCI Insight 2016; 1. [PMID: 27347562 DOI: 10.1172/jci.insight.86987] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Pulmonary arterial (PA) stiffness is associated with increased mortality in patients with pulmonary hypertension (PH); however, the role of PA stiffening in the pathogenesis of PH remains elusive. Here, we show that distal vascular matrix stiffening is an early mechanobiological regulator of experimental PH. We identify cyclooxygenase-2 (COX-2) suppression and corresponding reduction in prostaglandin production as pivotal regulators of stiffness-dependent vascular cell activation. Atomic force microscopy microindentation demonstrated early PA stiffening in experimental PH and human lung tissue. Pulmonary artery smooth muscle cells (PASMC) grown on substrates with the stiffness of remodeled PAs showed increased proliferation, decreased apoptosis, exaggerated contraction, enhanced matrix deposition, and reduced COX-2-derived prostanoid production compared with cells grown on substrates approximating normal PA stiffness. Treatment with a prostaglandin I2 analog abrogated monocrotaline-induced PA stiffening and attenuated stiffness-dependent increases in proliferation, matrix deposition, and contraction in PASMC. Our results suggest a pivotal role for early PA stiffening in PH and demonstrate the therapeutic potential of interrupting mechanobiological feedback amplification of vascular remodeling in experimental PH.
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Affiliation(s)
- Fei Liu
- Molecular and Integrative Physiological Sciences, Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Christina Mallarino Haeger
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Paul B Dieffenbach
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Delphine Sicard
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Izabela Chrobak
- Lovelace Respiratory Research Institute, Albuquerque, New Mexico, USA
| | - Anna Maria F Coronata
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Margarita M Suárez Velandia
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sally Vitali
- Department of Anesthesia, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Romain A Colas
- Center for Experimental Therapeutics and Reperfusion Injury, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Paul C Norris
- Center for Experimental Therapeutics and Reperfusion Injury, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Aleksandar Marinković
- Molecular and Integrative Physiological Sciences, Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Xiaoli Liu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jun Ma
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Chase D Rose
- Department of Anesthesia, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Seon-Jin Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Medical Genomics Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, Korea
| | - Suzy A A Comhair
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Serpil C Erzurum
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jacob D McDonald
- Lovelace Respiratory Research Institute, Albuquerque, New Mexico, USA
| | - Charles N Serhan
- Center for Experimental Therapeutics and Reperfusion Injury, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stephen R Walsh
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel J Tschumperlin
- Molecular and Integrative Physiological Sciences, Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts, USA; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Laura E Fredenburgh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Baggen VJM, Driessen MMP, Post MC, van Dijk AP, Roos-Hesselink JW, van den Bosch AE, Takkenberg JJM, Sieswerda GT. Echocardiographic findings associated with mortality ortransplant in patients with pulmonary arterial hypertension:A systematic review and meta-analysis. Neth Heart J 2016; 24:374-389. [PMID: 27189216 PMCID: PMC4887306 DOI: 10.1007/s12471-016-0845-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Identification of patients at risk of deterioration is essential to guide clinical management in pulmonary arterial hypertension (PAH). This study aims to provide a comprehensive overview of well-investigated echocardiographic findings that are associated with clinical deterioration in PAH. Methods MEDLINE and EMBASE databases were systematically searched for longitudinal studies published by April 2015 that reported associations between echocardiographic findings and mortality, transplant or clinical worsening. Meta-analysis using random effect models was performed for echocardiographic findings investigated by four or more studies. In case of statistical heterogeneity a sensitivity analysis was conducted. Results Thirty-seven papers investigating 51 echocardiographic findings were included. Meta-analysis of univariable hazard ratios (HRs) and sensitivity analysis showed that presence of pericardial effusion (pooled HR 1.70; 95 % CI 1.44–1.99), right atrial area (pooled HR 1.71; 95 % CI 1.38–2.13) and tricuspid annular plane systolic excursion (TAPSE; pooled HR 1.72; 95 % CI 1.34–2.20) were the most well-investigated and robust predictors of mortality or transplant. Conclusions This meta-analysis substantiates the clinical yield of specific echocardiographic findings in the prognostication of PAH patients in day-to-day practice. In particular, pericardial effusion, right atrial area and TAPSE are of prognostic value. Electronic supplementary material The online version of this article (doi: 10.1007/s12471-016-0845-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- V J M Baggen
- Department of Cardiology, University Medical Centre Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - M M P Driessen
- Department of Cardiology, University Medical Centre Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - M C Post
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - A P van Dijk
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J W Roos-Hesselink
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - A E van den Bosch
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - J J M Takkenberg
- Department of Cardio-Thoracic Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - G T Sieswerda
- Department of Cardiology, University Medical Centre Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
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Tian L, Wang Z, Liu Y, Eickhoff JC, Eliceiri KW, Chesler NC. Validation of an arterial constitutive model accounting for collagen content and crosslinking. Acta Biomater 2016; 31:276-287. [PMID: 26654765 DOI: 10.1016/j.actbio.2015.11.058] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 11/20/2015] [Accepted: 11/29/2015] [Indexed: 11/19/2022]
Abstract
During the progression of pulmonary hypertension (PH), proximal pulmonary arteries (PAs) increase in both thickness and stiffness. Collagen, a component of the extracellular matrix, is mainly responsible for these changes via increased collagen fiber amount (or content) and crosslinking. We sought to differentiate the effects of collagen content and cross-linking on mouse PA mechanical changes using a constitutive model with parameters derived from experiments in which collagen content and cross-linking were decoupled during hypoxic pulmonary hypertension (HPH). We employed an eight-chain orthotropic element model to characterize collagen's mechanical behavior and an isotropic neo-Hookean form to represent elastin. Our results showed a strong correlation between the material parameter related to collagen content and measured collagen content (R(2)=0.82, P<0.0001) and a moderate correlation between the material parameter related to collagen crosslinking and measured crosslinking (R(2)=0.24, P=0.06). There was no significant change in either the material parameter related to elastin or the measured elastin content from histology. The model-predicted pressure at which collagen begins to engage was ∼25mmHg, which is consistent with experimental observations. We conclude that this model may allow us to predict changes in the arterial extracellular matrix from measured mechanical behavior in PH patients, which may provide insight into prognoses and the effects of therapy. STATEMENT OF SIGNIFICANCE The literature has proposed several constitutive models to describe the mechanical effects of arterial collagen but none separates collagen content from crosslinking. Given that both are critical to arterial mechanics, the novel model described here does so. Furthermore, our novel model is well tested by experimental data; model parameters were reasonably correlated with measured collagen content and crosslinking and the model-predicted collagen transition stretch was consistent with that obtained experimentally. Given that arterial collagen structural changes and collagen engagement are critical to arterial stiffening in several disease states, this model, by linking mechanical and biological properties, may allow us to predict important biological changes during disease progression from measured mechanical behavior.
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Affiliation(s)
- Lian Tian
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Zhijie Wang
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Yuming Liu
- Laboratory for Optical and Computational Instrumentation, University of Wisconsin-Madison, Madison, WI, USA
| | - Jens C Eickhoff
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA
| | - Kevin W Eliceiri
- Laboratory for Optical and Computational Instrumentation, University of Wisconsin-Madison, Madison, WI, USA
| | - Naomi C Chesler
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA.
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Ghio S, Schirinzi S, Pica S. Pulmonary arterial compliance: How and why should we measure it? Glob Cardiol Sci Pract 2015; 2015:58. [PMID: 26779530 PMCID: PMC4710864 DOI: 10.5339/gcsp.2015.58] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 08/27/2015] [Indexed: 12/20/2022] Open
Abstract
The pulmonary circulation is a high-flow/low-pressure system, coupled with a flow generator chamber-the right ventricle-, which is relatively unable to tolerate increases in afterload. A right heart catheterization, using a fluid-filled, balloon-tipped Swan-Ganz catheter allows the measurement of all hemodynamic parameters characterizing the pulmonary circulation: the inflow pressure, an acceptable estimate the outflow pressure, and the pulmonary blood flow. However, the study of the pulmonary circulation as a continuous flow system is an oversimplification and a thorough evaluation of the pulmonary circulation requires a correct understanding of the load that the pulmonary vascular bed imposes on the right ventricle, which includes static and dynamic components. This is critical to assess the prognosis of patients with pulmonary hypertension or with heart failure. Pulmonary compliance is a measure of arterial distensibility and, either alone or in combination with pulmonary vascular resistance, gives clinicians the possibility of a good prognostic stratification of patients with heart failure or with pulmonary hypertension. The measurement of pulmonary arterial compliance should be included in the routine clinical evaluation of such patients.
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Affiliation(s)
- Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Sandra Schirinzi
- Division of Cardiology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Silvia Pica
- Division of Cardiology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
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Shafie D, Dohaei A, Amin A, Taghavi S, Naderi N. Pulmonary Vascular Capacitance as a Predictor of Vasoreactivity in Idiopathic Pulmonary Arterial Hypertension Tested by Adenosine. Res Cardiovasc Med 2015; 4:e28945. [PMID: 26528452 PMCID: PMC4623377 DOI: 10.5812/cardiovascmed.28945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Revised: 06/09/2015] [Accepted: 07/01/2015] [Indexed: 11/16/2022] Open
Abstract
Background: Acute pulmonary vasoreactivity testing has been recommended in the diagnostic work-up of patients with idiopathic pulmonary arterial hypertension (IPAH). Pulmonary arteriolar capacitance (Cp) approximated by stroke volume divided by pulmonary pulse pressure (SV/PP) is considered as an independent predictor of mortality in patients with IPAH. Objectives: We sought to evaluate any differences in baseline and adenosine Cp between vasoreactive and non-vasoreactive IPAH patients tested with adenosine. Patients and Methods: Fourteen patients with IPAH and a vasoreactive adenosine vasoreactivity testing according to the ESC guidelines were compared with 24 IPAH patients with nonreactive adenosine test results. Results: There were no statistical significant differences between the two groups regarding NYHA class, body surface area, heart rate, and systemic blood pressure during right heart catheterization. Hemodynamic study showed no statistical significant differences in cardiac output/Index, mean pulmonary artery pressure, pulmonary vascular resistance, and baseline Cp between the two groups. There was a statistical significant but weak increase in adenosine Cp in vasoreactive group compared to non-reactive group (P = 0.04). Multivariable analysis showed an association between Cp and vasoreactivity (Beta = 2, P = 0.04, OR = 0.05 (95%CI = 0.003 - 0.9). Conclusions: Cp could be considered as an index for the prediction of vasoreactivity in patients with IPAH. Prediction of long-term response to calcium channel blockers in patients with IPAH and a positive vasoreactive test by this index should be addressed in further studies.
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Affiliation(s)
- Davood Shafie
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, IR Iran
| | - Abolfazl Dohaei
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Ahmad Amin
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Sepideh Taghavi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Nasim Naderi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Nasim Naderi, Rajaie Cardiovascular Medical and Research Center, Vali-Asr St., Niayesh Blvd, Tehran, IR Iran. Tel: +98-2123922115, Fax: +98-2122055594, E-mail:
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Scarsini R, Prioli MA, Milano EG, Castellani C, Pesarini G, Assael BM, Vassanelli C, Ribichini FL. Hemodynamic predictors of long term survival in end stage cystic fibrosis. Int J Cardiol 2015; 202:221-5. [PMID: 26397415 DOI: 10.1016/j.ijcard.2015.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 09/08/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH) is often found in cystic fibrosis (CF) patients affected by end-stage lung disease but its impact on outcome remains unclear. Pulmonary arterial compliance (PAC) is an important determinant of right ventricle (RV) workload and it is a strong predictor of survival in other forms of PH. The aim of this study is to investigate whether PAC is a predictor of long-term prognosis in a population of CF patients affected by advanced lung disease. METHODS Between 2000 and 2014, 178 patients with CF have been evaluated for lung transplantation in our CF Center. Right heart catheterization (RHC) and follow up data were retrievable and analyzed in 141 of them. PAC was defined as the ratio between stroke volume (SV) and pulse pressure (PP) at heart catheterization. The association of PAC with survival was tested at 4 years and compared to other hemodynamic parameters. RESULTS PH prevalence was 56.4%. Most patients had mild elevation of pulmonary artery pressure (PAP). No difference in mortality was observed in patients with PH compared to patients with normal PAP (HR 0.95: 95% CI 0.49-1.89, p=0.89). At receiver operating characteristic curve (ROC) analysis, the optimal prognostic cut-off point of PAC was 1.95 ml/mmHg. An impaired PAC (≤1.95 ml/mmHg) was a strong independent predictor of long-term mortality (HR 3.44: 95% CI 1.51-7.85: p=0.003). CONCLUSIONS Impaired PAC is associated with poor prognosis in CF patients awaiting lung transplantation. Other traditional hemodynamic parameters add no prognostic information.
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Affiliation(s)
- Roberto Scarsini
- Department of Medicine, Section of Cardiology, University of Verona, Verona, Italy.
| | - Maria A Prioli
- Department of Medicine, Section of Cardiology, University of Verona, Verona, Italy
| | - Elena G Milano
- Department of Medicine, Section of Cardiology, University of Verona, Verona, Italy
| | | | - Gabriele Pesarini
- Department of Medicine, Section of Cardiology, University of Verona, Verona, Italy
| | | | - Corrado Vassanelli
- Department of Medicine, Section of Cardiology, University of Verona, Verona, Italy
| | - Flavio L Ribichini
- Department of Medicine, Section of Cardiology, University of Verona, Verona, Italy
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Weir-McCall JR, Struthers AD, Lipworth BJ, Houston JG. The role of pulmonary arterial stiffness in COPD. Respir Med 2015; 109:1381-90. [PMID: 26095859 PMCID: PMC4646836 DOI: 10.1016/j.rmed.2015.06.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 05/10/2015] [Accepted: 06/10/2015] [Indexed: 12/23/2022]
Abstract
COPD is the second most common cause of pulmonary hypertension, and is a common complication of severe COPD with significant implications for both quality of life and mortality. However, the use of a rigid diagnostic threshold of a mean pulmonary arterial pressure (mPAP) of ≥25mHg when considering the impact of the pulmonary vasculature on symptoms and disease is misleading. Even minimal exertion causes oxygen desaturation and elevations in mPAP, with right ventricular hypertrophy and dilatation present in patients with mild to moderate COPD with pressures below the threshold for diagnosis of pulmonary hypertension. This has significant implications, with right ventricular dysfunction associated with poorer exercise capability and increased mortality independent of pulmonary function tests. The compliance of the pulmonary artery (PA) is a key component in decoupling the right ventricle from the pulmonary bed, allowing the right ventricle to work at maximum efficiency and protecting the microcirculation from large pressure gradients. PA stiffness increases with the severity of COPD, and correlates well with the presence of exercise induced pulmonary hypertension. A curvilinear relationship exists between PA distensibility and mPAP and pulmonary vascular resistance (PVR) with marked loss of distensibility before a rapid rise in mPAP and PVR occurs with resultant right ventricular failure. This combination of features suggests PA stiffness as a promising biomarker for early detection of pulmonary vascular disease, and to play a role in right ventricular failure in COPD. Early detection would open this up as a potential therapeutic target before end stage arterial remodelling occurs. Pulmonary hypertension is common in COPD. Right ventricular remodeling occurs at pressures below the diagnostic threshold of PH. Pulmonary arterial stiffening occurs early in the development of PH. Non-invasive measurement of pulmonary stiffness may serve as an early biomarker of PH.
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Affiliation(s)
- Jonathan R Weir-McCall
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, Dundee, United Kingdom.
| | - Allan D Struthers
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, Dundee, United Kingdom
| | - Brian J Lipworth
- Scottish Centre for Respiratory Research, Medical Research Institute, University of Dundee, Dundee, United Kingdom
| | - J Graeme Houston
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, University of Dundee, Dundee, United Kingdom
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D'Andrea A, Stanziola A, Di Palma E, Martino M, D'Alto M, Dellegrottaglie S, Cocchia R, Riegler L, Betancourt Cordido MV, Lanza M, Maglione M, Diana V, Calabrò R, Russo MG, Vannan M, Bossone E. Right Ventricular Structure and Function in Idiopathic Pulmonary Fibrosis with or without Pulmonary Hypertension. Echocardiography 2015; 33:57-65. [DOI: 10.1111/echo.12992] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Antonello D'Andrea
- Department of Cardiology; Second University of Naples; Monaldi Hospital; “dei Colli - Monaldi” Hospitals; Naples Italy
| | - Anna Stanziola
- Division of Pneumology; Federico II University; Monaldi Hospital; “dei Colli - Monaldi” Hospitals; Naples Italy
| | - Enza Di Palma
- Department of Cardiology; Second University of Naples; Monaldi Hospital; “dei Colli - Monaldi” Hospitals; Naples Italy
| | - Maria Martino
- Division of Pneumology; Federico II University; Monaldi Hospital; “dei Colli - Monaldi” Hospitals; Naples Italy
| | - Michele D'Alto
- Department of Cardiology; Second University of Naples; Monaldi Hospital; “dei Colli - Monaldi” Hospitals; Naples Italy
| | | | - Rosangela Cocchia
- Department of Cardiology; Second University of Naples; Monaldi Hospital; “dei Colli - Monaldi” Hospitals; Naples Italy
| | - Lucia Riegler
- Department of Cardiology; Second University of Naples; Monaldi Hospital; “dei Colli - Monaldi” Hospitals; Naples Italy
| | | | - Maurizia Lanza
- Division of Pneumology; Federico II University; Monaldi Hospital; “dei Colli - Monaldi” Hospitals; Naples Italy
| | - Marco Maglione
- Global Marketing US Cardio - Esaote Ultrasound Technology; Florence Italy
| | - Veronica Diana
- Department of Cardiology; Second University of Naples; Monaldi Hospital; “dei Colli - Monaldi” Hospitals; Naples Italy
| | - Raffaele Calabrò
- Department of Cardiology; Second University of Naples; Monaldi Hospital; “dei Colli - Monaldi” Hospitals; Naples Italy
| | - Maria Giovanna Russo
- Department of Cardiology; Second University of Naples; Monaldi Hospital; “dei Colli - Monaldi” Hospitals; Naples Italy
| | - Mani Vannan
- Department of Cardiovascular Medicine; Piedmont Heart Institute; Atlanta Georgia
| | - Eduardo Bossone
- Department of Cardiology and Cardiac Surgery; “San Giovanni di Dio e Ruggi d'Aragona” University Hospital; Salern Italy
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Harrison A, Hatton N, Ryan JJ. The right ventricle under pressure: evaluating the adaptive and maladaptive changes in the right ventricle in pulmonary arterial hypertension using echocardiography (2013 Grover Conference series). Pulm Circ 2015; 5:29-47. [PMID: 25992269 DOI: 10.1086/679699] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 08/19/2014] [Indexed: 01/02/2023] Open
Abstract
The importance of the right ventricle (RV) in pulmonary arterial hypertension (PAH) has been gaining increased recognition. This has included a reconceptualization of the RV as part of an RV-pulmonary circulation interrelated unit and the observation that RV function is a major determinant of prognosis in PAH. Noninvasive imaging of RV size and function is critical to the longitudinal management of patients with PAH, and continued understanding of the pathophysiology of pulmonary vascular disease relies on the response of the RV to pulmonary vascular remodeling. Echocardiography, in particular the newer echocardiographic measurements and techniques, allows easy, readily accessible means to assess and follow RV size and function.
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Affiliation(s)
- Alexis Harrison
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Nathan Hatton
- Division of Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
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