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Louw EH, Van Heerden JA, Kalla IS, Maarman GJ, Nxumalo Z, Thienemann F, Huaman MA, Magee M, Allwood BA. Scoping review of post-TB pulmonary vascular disease: Proceedings from the 2nd International Post-Tuberculosis Symposium. Pulm Circ 2024; 14:e12424. [PMID: 39268398 PMCID: PMC11391472 DOI: 10.1002/pul2.12424] [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: 06/14/2024] [Accepted: 07/15/2024] [Indexed: 09/15/2024] Open
Abstract
Tuberculosis (TB) may cause significant long-term cardiorespiratory complications, of which pulmonary vascular disease is most under-recognized. TB is rarely listed as a cause of pulmonary hypertension (PH) in most PH guidelines, yet PH may develop at various stages in the time course of TB, from active infection through to the post-TB period. Predisposing risk factors for the development of PH are likely multifactorial, involving active TB disease and post-TB lung disease (PTLD), host-related and environment-related factors. Moreover, post-TB PH should likely be classified in Group 3 PH, with the pathogenesis similarly complex and multifactorial as other Group 3 PH causes. Identifying risk factors that predispose to post-TB PH may aid in developing risk stratification criteria for early identification and referral for confirmatory diagnostic tests. Given that universal screening for PH in TB survivors may be impractical and unfeasible, a targeted screening approach for high-risk individuals would be sensible. In this scoping review of post-TB PH, resulting from the proceedings of the 2nd International Post-Tuberculosis Symposium, we aim to describe the epidemiology, risk factors, and pathophysiology of post-TB PH. We emphasize diagnosing PH with an alternative set of diagnostic guidelines in resource-constrained settings where right heart catheterization may not be feasible. Research to describe the burden and distribution of post-TB PH should be prioritized as there is a current gap in knowledge regarding the prevalence and incidence of post-TB PH among persons with TB.
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Affiliation(s)
- Elizabeth H Louw
- Department of Medicine, Division of Pulmonology Stellenbosch University & Tygerberg Hospital Cape Town South Africa
| | - Jennifer A Van Heerden
- Nuffield Department of Surgical Sciences, Medical Sciences Division University of Oxford Oxford UK
| | - Ismail S Kalla
- Department of Medicine, Division of Pulmonology University of Witwatersrand Johannesburg South Africa
| | - Gerald J Maarman
- Department of Biomedical Sciences, Centre for Cardio-Metabolic Research in Africa (CARMA), Division of Medical Physiology, Faculty of Medicine & Health Sciences Stellenbosch University Cape Town South Africa
| | - Zoliswa Nxumalo
- Department of Medicine Stellenbosch University & Tygerberg Hospital Cape Town South Africa
| | - Friedrich Thienemann
- Department of Medicine and Cape Heart Institute, General Medicine & Global Health Research Unit, Faculty of Health Science University of Cape Town Cape Town South Africa
- Department of Internal Medicine, University Hospital Zurich University of Zurich Zurich Switzerland
| | - Moises A Huaman
- Hubert Department of Global Health, Rollins School of Public Health Emory University Atlanta Georgia USA
| | - Matthew Magee
- Infectious Diseases Research Unit, CCTST K Scholars Program University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Brian A Allwood
- Department of Medicine, Division of Pulmonology Stellenbosch University & Tygerberg Hospital Cape Town South Africa
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Niyogi SG, Singh A, Kumar B, Mishra AK, Puri GD. Right Atrial Strain in Pediatric Pulmonary Hypertension-A Prospective Observational Study. Pediatr Cardiol 2024:10.1007/s00246-024-03523-8. [PMID: 38777858 DOI: 10.1007/s00246-024-03523-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 05/06/2024] [Indexed: 05/25/2024]
Abstract
Right ventricular (RV) afterload due to elevated pulmonary arterial (PA) pressure in pulmonary hypertension (PH) causes long-term right atrial (RA) remodeling and dysfunction. RA function has been shown to correlate with PA pressures and outcome in both adult and pediatric patients with PH. We studied the role of RA strain in estimating PA pressures in congenital heart disease (CHD)-associated PH. Children below 12 years undergoing elective repair of CHD with left-to-right shunts and echocardiographic evidence of PH were included. RA reservoir, conduit and contractile strain along with conventional measures of RV function and PA pressure were measured using transthoracic echocardiography after induction of anaesthesia. Pre-and post-repair invasive PA pressures were measured after surgical exposure. 51 children with a median age of 24 months (range 4-144 months) were included, most of whom were undergoing VSD closure. Contractile RA strain showed good correlation with pre-repair systolic PA pressure in mmHg (r = 0.59, 95%CI 0.37-0.75) or expressed as a percentage of SBP (r = 0.67, 95%CI 0.49-0.80). It also predicted persistent postoperative PH as well as pre-repair pulmonary artery acceleration time and right ventricular systolic pressure measured from tricuspid regurgitation jet. The trends of correlation observed suggest a possible prognostic role of RA strain in ACHD with PH and potential utility in its echocardiographic assessment. The observed findings merit deeper evaluation in larger cohorts.
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Affiliation(s)
- Subhrashis Guha Niyogi
- Department of Anaesthesia, All India Institute of Medical Sciences, Kalyani, West Bengal, India
| | - Avneet Singh
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Bhupesh Kumar
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India.
| | - Anand Kumar Mishra
- Department of Cardiothoracic and Vascular Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Goverdhan Dutt Puri
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India
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Kadoglou NPE, Khattab E, Velidakis N, Gkougkoudi E, Myrianthefs MM. The Role of Echocardiography in the Diagnosis and Prognosis of Pulmonary Hypertension. J Pers Med 2024; 14:474. [PMID: 38793056 PMCID: PMC11122427 DOI: 10.3390/jpm14050474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/26/2024] Open
Abstract
The right heart catheterisation constitutes the gold standard for pulmonary hypertension (PH) diagnosis. However, echocardiography remains a reliable, non-invasive, inexpensive, convenient, and easily reproducible modality not only for the preliminary screening of PH but also for PH prognosis. The aim of this review is to describe a cluster of echocardiographic parameters for the detection and prognosis of PH and analyse the challenges of echocardiography implementation in patients with suspected or established PH. The most important echocardiographic index is the calculation of pulmonary arterial systolic pressure (PASP) through the tricuspid regurgitation (TR). It has shown high correlation with invasive measurement of pulmonary pressure, but several drawbacks have questioned its accuracy. Besides this, the right ventricular outflow track acceleration time (RVOT-AT) has been proposed for PH diagnosis. A plethora of echocardiographic indices: right atrial area, pericardial effusion, the tricuspid annular plane systolic excursion (TAPSE), the TAPSE/PASP ratio, tricuspid annular systolic velocity (s'), can reflect the severity and prognosis of PH. Recent advances in echocardiography with 3-dimensional right ventricular (RV) ejection fraction, RV free wall strain and right atrial strain may further assist the prognosis of PH.
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Affiliation(s)
- Nikolaos P. E. Kadoglou
- Medical School, University of Cyprus, 215/6 Old Road Lefkosias-Lemesou, Aglatzia, Nicosia 2029, Cyprus; (E.K.); (N.V.); (E.G.)
- Cardiology Department, Nicosia General Hospital, Lemesou 215, Strovolos, Nicosia 2029, Cyprus;
| | - Elina Khattab
- Medical School, University of Cyprus, 215/6 Old Road Lefkosias-Lemesou, Aglatzia, Nicosia 2029, Cyprus; (E.K.); (N.V.); (E.G.)
- Cardiology Department, Nicosia General Hospital, Lemesou 215, Strovolos, Nicosia 2029, Cyprus;
| | - Nikolaos Velidakis
- Medical School, University of Cyprus, 215/6 Old Road Lefkosias-Lemesou, Aglatzia, Nicosia 2029, Cyprus; (E.K.); (N.V.); (E.G.)
| | - Evaggelia Gkougkoudi
- Medical School, University of Cyprus, 215/6 Old Road Lefkosias-Lemesou, Aglatzia, Nicosia 2029, Cyprus; (E.K.); (N.V.); (E.G.)
| | - Michael M. Myrianthefs
- Cardiology Department, Nicosia General Hospital, Lemesou 215, Strovolos, Nicosia 2029, Cyprus;
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Alerhand S, Adrian RJ. What echocardiographic findings differentiate acute pulmonary embolism and chronic pulmonary hypertension? Am J Emerg Med 2023; 72:72-84. [PMID: 37499553 DOI: 10.1016/j.ajem.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Pulmonary embolism (PE) and pulmonary hypertension (PH) are potentially fatal disease states. Early diagnosis and goal-directed management improve outcomes and survival. Both conditions share several echocardiographic findings of right ventricular dysfunction. This can inadvertently lead to incorrect diagnosis, inappropriate and potentially harmful management, and delay in time-sensitive therapies. Fortunately, bedside echocardiography imparts a few critical distinctions. OBJECTIVE This narrative review describes eight physiologically interdependent echocardiographic parameters that help distinguish acute PE and chronic PH. The manuscript details each finding along with associated pathophysiology and summarization of the literature evaluating diagnostic utility. This guide then provides pearls and pitfalls with high-quality media for the bedside evaluation. DISCUSSION The echocardiographic parameters suggesting acute or chronic right ventricular dysfunction (best used in combination) are: 1. Right heart thrombus (acute PE) 2. Right ventricular free wall thickness (acute ≤ 5 mm, chronic > 5 mm) 3. Tricuspid regurgitation pressure gradient (acute ≤ 46 mmHg, chronic > 46 mmHg, corresponding to tricuspid regurgitation maximal velocity ≤ 3.4 m/sec and > 3.4 m/sec, respectively) 4. Pulmonary artery acceleration time (acute ≤ 60-80 msec, chronic < 105 msec) 5. 60/60 sign (acute) 6. Pulmonary artery early-systolic notching (proximally-located, higher-risk PE) 7. McConnell's sign (acute) 8. Right atrial enlargement (equal to left atrial size suggests acute, greater than left atrial size suggests chronic). CONCLUSIONS Emergency physicians must appreciate the echocardiographic findings and associated pathophysiology that help distinguish acute and chronic right ventricular dysfunction. In the proper clinical context, these findings can point towards PE or PH, thereby leading to earlier goal-directed management.
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Affiliation(s)
- Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, 150 Bergen Street, Newark, NJ 07103, USA.
| | - Robert James Adrian
- Department of Emergency Medicine, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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Jervan Ø, Dhayyat A, Gleditsch J, Haukeland-Parker S, Tavoly M, Klok FA, Rashid D, Stavem K, Ghanima W, Steine K. Demographic, clinical, and echocardiographic factors associated with residual perfusion defects beyond six months after pulmonary embolism. Thromb Res 2023; 229:7-14. [PMID: 37356172 DOI: 10.1016/j.thromres.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/22/2023] [Accepted: 06/04/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Residual perfusion defects (RPD) after pulmonary embolism (PE) are common. PRIMARY AIM This study aimed to determine the prevalence of RPD in a cohort diagnosed with PE 6-72 months earlier, and to determine demographic, clinical, and echocardiographic variables associated with RPD. METHODS Patients aged 18-75 years with prior PE, confirmed by computed tomography pulmonary angiography 6-72 months earlier, were included. Participants (N = 286) completed a diagnostic work-up consisting of transthoracic echocardiography and ventilation/perfusion scintigraphy. Demographic, clinical, and echocardiographic characteristics between participants with RPD and those without RPD were explored in univariate analyses using t-test or Mann-Whitney U test. Multiple logistic regression analysis was used to assess the association between selected variables and RPD. RESULTS RPD were detected in 72/286 patients (25.2 %, 95 % CI:20.5 %-30.5 %). Greater tricuspid annular plane systolic excursion (TAPSE) (adjusted odds ratio (aOR) 1.10, 95 % CI:1.00-1.21, p = 0.048) at echocardiographic follow-up, greater thrombotic burden at diagnosis, as assessed by mean bilateral proximal extension of the clot (MBPEC) score 3-4 (aOR 2.08, 95 % CI:1.06-4.06, p = 0.032), and unprovoked PE (aOR 2.25, 95 % CI:1.13-4.48, p = 0.021) were independently associated with increased risk of RPD, whereas increased pulmonary artery acceleration time was associated with a lower risk of RPD (aOR 0.72, 95 % CI:0.62-0.83, p < 0.001, per 10 ms). Dyspnoea was not associated with RPD. CONCLUSION RPD were common after PE. Reduced pulmonary artery acceleration time and greater TAPSE on echocardiography at follow-up, greater thrombotic burden at diagnosis, and unprovoked PE were associated with RPD.
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Affiliation(s)
- Øyvind Jervan
- Department of Cardiology, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Adam Dhayyat
- Department of Cardiology, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jostein Gleditsch
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Radiology, Østfold Hospital, Kalnes, Norway
| | - Stacey Haukeland-Parker
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Physical Medicine and Rehabilitation, Østfold Hospital, Kalnes, Norway
| | - Mazdak Tavoly
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Diyar Rashid
- Department of Radiology, Østfold Hospital, Kalnes, Norway
| | - Knut Stavem
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway; Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Waleed Ghanima
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Division of Medicine, Østfold Hospital, Kalnes, Norway; Department of Hematology, Oslo University Hospital, Oslo, Norway
| | - Kjetil Steine
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
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Dong TX, Zhu Q, Wang ST, Wang YH, Li GY, Kong FX, Ma CY. Diagnostic and prognostic value of echocardiography in pulmonary hypertension: an umbrella review of systematic reviews and meta-analyses. BMC Pulm Med 2023; 23:253. [PMID: 37430308 DOI: 10.1186/s12890-023-02552-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/06/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND The role of echocardiography in the diagnostic and prognostic assessment of pulmonary hypertension (PH) has been widely studied recently. However, these findings have not undergone normative evaluation and may provide confusing evidence for clinicians. To evaluate and summarize existing evidence, we performed an umbrella review. METHODS Systematic reviews and meta-analyses were searched in PubMed, Embase, Web of Science, and Cochrane Library from inception to September 4, 2022. The methodological quality of the included studies was assessed using Assessment of Multiple Systematic Reviews (AMSTAR), and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the quality of evidence. RESULTS Thirteen meta-analyses (nine diagnostic and four prognostic studies) were included after searching four databases. The methodological quality of the included studies was rated as high (62%) or moderate (38%) by AMSTAR. The thirteen included meta-analyses involved a total of 28 outcome measures. The quality of evidence for these outcomes were high (7%), moderate (29%), low (39%), and very low (25%) using GRADE methodology. In the detection of PH, the sensitivity of systolic pulmonary arterial pressure is 0.85-0.88, and the sensitivity and specificity of right ventricular outflow tract acceleration time are 0.84. Pericardial effusion, right atrial area, and tricuspid annulus systolic displacement provide prognostic value in patients with pulmonary arterial hypertension with hazard ratios between 1.45 and 1.70. Meanwhile, right ventricular longitudinal strain has independent prognostic value in patients with PH, with a hazard ratio of 2.96-3.67. CONCLUSION The umbrella review recommends echocardiography for PH detection and prognosis. Systolic pulmonary arterial pressure and right ventricular outflow tract acceleration time can be utilized for detection, while several factors including pericardial effusion, right atrial area, tricuspid annular systolic displacement, and right ventricular longitudinal strain have demonstrated prognostic significance. TRIAL REGISTRATION PROSPERO (CRD42022356091), https://www.crd.york.ac.uk/prospero/ .
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Affiliation(s)
- Tian-Xin Dong
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, No. 155 Nanjing Bei Street, Shenyang, 110001, Liaoning, China
| | - Qing Zhu
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, No. 155 Nanjing Bei Street, Shenyang, 110001, Liaoning, China
- Clinical Medical Research Center of Imaging in Liaoning Province, Shenyang, Liaoning, China
| | - Shi-Tong Wang
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, No. 155 Nanjing Bei Street, Shenyang, 110001, Liaoning, China
- Clinical Medical Research Center of Imaging in Liaoning Province, Shenyang, Liaoning, China
| | - Yong-Huai Wang
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, No. 155 Nanjing Bei Street, Shenyang, 110001, Liaoning, China
- Clinical Medical Research Center of Imaging in Liaoning Province, Shenyang, Liaoning, China
| | - Guang-Yuan Li
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, No. 155 Nanjing Bei Street, Shenyang, 110001, Liaoning, China
- Clinical Medical Research Center of Imaging in Liaoning Province, Shenyang, Liaoning, China
| | - Fan-Xin Kong
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, No. 155 Nanjing Bei Street, Shenyang, 110001, Liaoning, China
- Clinical Medical Research Center of Imaging in Liaoning Province, Shenyang, Liaoning, China
| | - Chun-Yan Ma
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, No. 155 Nanjing Bei Street, Shenyang, 110001, Liaoning, China.
- Clinical Medical Research Center of Imaging in Liaoning Province, Shenyang, Liaoning, China.
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Orihara Y, Asakura M, Min KD, Matsumoto Y, Sunayama I, Nishimura K, Eguchi A, Okuhara Y, Ishihara M. Mean pulmonary artery pressure estimated by echocardiogram rapidly exceeds 20 mmHg from the normal range in patients with connective tissue disease. Heart Vessels 2023:10.1007/s00380-023-02267-4. [PMID: 37074476 DOI: 10.1007/s00380-023-02267-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 04/05/2023] [Indexed: 04/20/2023]
Abstract
Earlier intervention for pulmonary hypertension (PH) has been reported to improve the prognosis of patients with connective tissue disease (CTD). However, it is not fully elucidated how rapidly PH develops in patients showing normal mean pulmonary arterial pressure (mPAP) at the index investigation. We evaluated 191 CTD patients with normal mPAP retrospectively. The mPAP was estimated by the formerly defined method employing echocardiography (mPAPecho). We investigated predictive factors that predict increasing mPAPecho at follow-up transthoracic echocardiography (TTE) using uni- and multi variable analysis. The mean age was 61.5 years old, and 160 patients were female. The percentage of patients in whom mPAPecho exceeded 20 mmHg at follow-up TTE was 38%. Multivariable analysis revealed that acceleration time/ejection time (AcT/ET) measured at the right ventricular outflow tract at initial TTE was independently associated with the consequent increase of mPAPecho at the follow-up TTE. When using 0.43 of best cutoff value in AcT/ET calculated by receiver operating characteristic analysis, the change in mPAPecho in patients with low AcT/ET was significantly higher than in those with high AcT/ET (3.05 mmHg in patients with AcT/ET < 0.43 and 1.00 mmHg in patients with AcT/ET ≥ 0.43, p < 0.001). Thirty-eight percent of CTD patients who show the normal estimated mPAP by TTE develop gradual elevation of mPAP to the level to consider early intervention within 2 years. AcT/ET at initial TTE can predict increasing mPAP at follow-up TTE.
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Affiliation(s)
- Yoshiyuki Orihara
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Masanori Asakura
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Kyung-Duk Min
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Yuki Matsumoto
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Isamu Sunayama
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Koichi Nishimura
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Akiyo Eguchi
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Yoshitaka Okuhara
- Department of Cardiology, Hakuhokai Central Hospital, Amagasaki, Hyogo, Japan
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
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Wang YC, Lin PL, Huang CH. Perioperative Echocardiographic Prediction of Pulmonary Hypertension by Pulmonary Artery Acceleration Time during Cardiac Surgery with Cardiopulmonary Bypass. J Am Soc Echocardiogr 2023:S0894-7317(23)00013-5. [PMID: 36646231 DOI: 10.1016/j.echo.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/01/2023] [Accepted: 01/02/2023] [Indexed: 01/15/2023]
Affiliation(s)
- Yi-Chia Wang
- Department of Anaesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Pei-Lin Lin
- Department of Anaesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Hsiang Huang
- Department of Anaesthesiology, National Taiwan University Hospital, Taipei, Taiwan
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Pastore MC, Ilardi F, Stefanini A, Mandoli GE, Palermi S, Bandera F, Benfari G, Esposito R, Lisi M, Pasquini A, Santoro C, Valente S, D’Andrea A, Cameli M. Bedside Ultrasound for Hemodynamic Monitoring in Cardiac Intensive Care Unit. J Clin Med 2022; 11:jcm11247538. [PMID: 36556154 PMCID: PMC9785677 DOI: 10.3390/jcm11247538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/03/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
Thanks to the advances in medical therapy and assist devices, the management of patients hospitalized in cardiac intensive care unit (CICU) is becoming increasingly challenging. In fact, Patients in the cardiac intensive care unit are frequently characterized by dynamic and variable diseases, which may evolve into several clinical phenotypes based on underlying etiology and its complexity. Therefore, the use of noninvasive tools in order to provide a personalized approach to these patients, according to their phenotype, may help to optimize the therapeutic strategies towards the underlying etiology. Echocardiography is the most reliable and feasible bedside method to assess cardiac function repeatedly, assisting clinicians not only in characterizing hemodynamic disorders, but also in helping to guide interventions and monitor response to therapies. Beyond basic echocardiographic parameters, its application has been expanded with the introduction of new tools such as lung ultrasound (LUS), the Venous Excess UltraSound (VexUS) grading system, and the assessment of pulmonary hypertension, which is fundamental to guide oxygen therapy. The aim of this review is to provide an overview on the current knowledge about the pathophysiology and echocardiographic evaluation of perfusion and congestion in patients in CICU, and to provide practical indications for the use of echocardiography across clinical phenotypes and new applications in CICU.
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Affiliation(s)
- Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
- Correspondence: (M.C.P.); (M.C.); Tel.: +39-057-758-5377 (M.C.P.)
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
- Mediterranea Cardiocentro, 80122 Naples, Italy
| | - Andrea Stefanini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
| | - Stefano Palermi
- Public Health Department, University of Naples Federico II, 80131 Naples, Italy
| | - Francesco Bandera
- Cardiology University Department, Heart Failure Unit, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
- Department of Biomedical Sciences for Health, University of Milano, 20122 Milan, Italy
| | - Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, 37129 Verona, Italy
| | - Roberta Esposito
- Department of Clinical Medicine and Surgery, Federico II University Hospital, 80131 Naples, Italy
| | - Matteo Lisi
- Department of Cardiovascular Disease—AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Viale Randi 5, 48121 Ravenna, Italy
| | - Annalisa Pasquini
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 20123 Rome, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
| | - Serafina Valente
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
| | - Antonello D’Andrea
- Department of Cardiology, Umberto I Hospital, 84014 Nocera Inferiore, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
- Correspondence: (M.C.P.); (M.C.); Tel.: +39-057-758-5377 (M.C.P.)
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10
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Dammassa V, Corradi F, Colombo CNJ, Mojoli F, Price S, Tavazzi G. Pulmonary artery acceleration time accuracy for systolic pulmonary artery pressure estimation in critically ill patients. Ultrasound J 2022; 14:26. [PMID: 35723841 PMCID: PMC9209611 DOI: 10.1186/s13089-022-00276-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/08/2022] [Indexed: 11/21/2022] Open
Abstract
Background Estimation of pulmonary pressures is of key importance in acute cardiovascular and respiratory failure. Pulmonary artery acceleration time (PAAT) has emerged as reliable parameter for the estimation of systolic pulmonary artery pressure (sPAP) in cardiological population with preserved right ventricular function. We sought to find whether PAAT correlates with sPAP in critically ill patients with and without right ventricular (RV) systolic dysfunction. Methods Observational study. We measured sPAP using continuous-wave Doppler analysis of tricuspid regurgitation velocity peak method and we assessed the validity of PAAT in estimating sPAP in patients admitted to adult intensive care unit (ICU) for acute cardiovascular and respiratory failure. Results We enrolled 236 patients admitted to cardiothoracic ICU for cardiovascular and respiratory failure (respectively: 129, 54.7% and 107, 45.3%). 114 (48.3%) had preserved RV systolic function (defined as TAPSE ≥ 17 mm), whilst 122 (51.7%) had RV systolic impairment (defined as TAPSE < 17 mm). A weak inverse correlation between PAAT and sPAP (ρ–0.189, p 0.0035) was observed in overall population, which was confirmed in those with preserved RV systolic PAAT and sPAP (ρ–0.361, p 0.0001). In patients with impaired RV systolic function no statistically significant correlation between PAAT and sPAP was demonstrated (p 0.2737). Adjusting PAAT values for log10, heart rate and RV ejection time did not modify the abovementioned correlations. Conclusions PAAT measurement to derive sPAP is not reliable in cardiothoracic critically ill patients, particularly in the coexistence of RV systolic impairment.
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11
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Lachance L, Conversy B, Wiggen K, Pavard C, Reinero C, Masseau I. No evidence of pulmonary hypertension revealed in an echographic evaluation of right-sided hemodynamics in hyperthyroid cats. J Feline Med Surg 2022; 24:e558-e567. [PMID: 36350661 PMCID: PMC9742920 DOI: 10.1177/1098612x221127102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Hyperthyroidism is a common endocrinopathy affecting middle-aged to elderly cats, with multisystemic repercussions. Hyperthyroid humans show decreased lung compliance and increased cardiac output with subsequent left heart failure leading to pulmonary capillary congestion. Prognosis worsens with the development of increased pulmonary vascular pressures (ie, pulmonary hypertension [PH]) in hyperthyroid humans. The effect of excess thyroid hormone concentration on pulmonary arterial hemodynamics is unknown in cats. Assessing pulmonary vascular pressures in veterinary medicine relies heavily on echocardiographic measurements performed at the level of the heart and pulmonary trunk. This study investigated right-sided cardiac and pulmonary arterial hemodynamics in hyperthyroid cats using echocardiography. METHODS Echocardiographic examinations of hyperthyroid cats identified through a bi-institutional database search were reviewed for the determination of systolic pulmonary arterial pressure (PAP) and 20 other metrics. Values were compared with those of a healthy cat group using non-parametric statistical analyses. RESULTS Systolic PAP could not be determined in 23/26 hyperthyroid and 13/14 healthy cats owing to unmeasurable tricuspid regurgitation flow velocity. Hyperthyroid cats were roughly twice as old (P <0.001) and had 2-4-fold higher respiratory rates (P <0.001) than healthy cats. Hyperthyroid cats showed an increase in acceleration time-to-ejection time ratio of pulmonary flow (1.4-fold, P = 0.001), pulmonary artery velocity time integral (1.2-1.6-fold, P = 0.001), maximal pulmonary velocity (1.3-1.7-fold, P = 0.002), stroke volume (1.5-fold, P = 0.001) and cardiac output (1.6-fold, P <0.001) vs healthy cats. None of the other echocardiographic metrics reached statistical significance. CONCLUSIONS AND RELEVANCE Systolic PAP estimation proved unsuitable as a sole measurement for the assessment of PH in hyperthyroid cats owing to the frequent inability to interrogate tricuspid regurgitant flow velocity. Hyperthyroid cats have altered echocardiographic measures of pulmonary hemodynamics dissimilar to those reported in hyperthyroid humans. Differential effects of thyrotoxic cardiomyopathy on ventricular systolic function may underlie species differences.
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Affiliation(s)
- Laury Lachance
- Department of Clinical Sciences,
Faculty of Veterinary Medicine, University of Montréal, Saint-Hyacinthe,
Canada
| | - Bérénice Conversy
- Department of Clinical Sciences,
Faculty of Veterinary Medicine, University of Montréal, Saint-Hyacinthe,
Canada
| | - Kelly Wiggen
- Department of Veterinary Medicine and
Surgery, University of Missouri Veterinary Health Center, College of Veterinary
Medicine, University of Missouri, Columbia, MO, USA
| | - Christophe Pavard
- Department of Clinical Sciences,
Faculty of Veterinary Medicine, University of Montréal, Saint-Hyacinthe,
Canada
| | - Carol Reinero
- Department of Veterinary Medicine and
Surgery, University of Missouri Veterinary Health Center, College of Veterinary
Medicine, University of Missouri, Columbia, MO, USA
| | - Isabelle Masseau
- Department of Clinical Sciences,
Faculty of Veterinary Medicine, University of Montréal, Saint-Hyacinthe,
Canada,Isabelle Masseau DVM, PhD, Dipl ACVR,
Department of Clinical Sciences, Faculty of Veterinary Medicine, University of
Montréal, 3200 Sicotte, Saint-Hyacinthe, QC J2S 2M2, Canada
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12
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Kubisa B, Kubisa A, Piotrowska M, Safranow K, Grodzki T, Peregud-Pogorzelska M. Right Heart Echocardiography Parameters and Other Predictors to Evaluate Mechanical Cardiac Support Necessity During Lung Transplantation. Transplant Proc 2022; 54:2307-2312. [PMID: 36180254 DOI: 10.1016/j.transproceed.2022.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 07/21/2022] [Accepted: 08/26/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Lung transplantation (LuTx) is a challenge when right heart function fails. Mechanical circulatory support (MCS) is then necessary. METHODS We aimed to investigate whether preoperative transthoracic echocardiography (TTE) can predict MCS use and help to exclude the sickest patients. Between 2011 and 2018, 52 patients at our institution received LuTx and qualified for this study: 35 bilateral, 16 single, 1 lobar [1] and 1 retransplantation procedure. Of these, 22 were operated using MCS and 30 without MCS. The patients were aged between 18 and 65 years, and 23 were women. The indications were lung fibrosis for 18 patients, chronic obstructive lung disease for 16, cystic fibrosis for 15, primary pulmonary hypertension for 2 and bronchiectasis for 1. TTE was performed up to 30 days before treatment and 1 to 7 days after. RESULTS Patients undergoing MCS versus patients not undergoing MCS: preoperative right ventricular systolic pressure 56.5 (30) vs 37.8 (11.5) mm Hg (P = .03); tricuspid regurgitation pressure gradient 48.7 (27) vs 30.2 (10.8) mm Hg (P = .015); tricuspid annular plane systolic excursion 17.8 (4.3) vs 19.9 (2.8) mm Hg (P = .04); pulmonary artery diameter 27.5 (5.2) vs 23.9 (4.1) mm (P = .004); age 41.9 (14.1) vs 54.3 (11.8) years (P = .001). Patients who were Dead versus patients who were alive pulmonary valve acceleration time of 82.8 (24.1) vs 104.9 (27.2) ms (hazard ratio [HR] = 0.959, 95% confidence interval [CI] = 0.923-0.996 per ms, P = .02) and pulmonary artery diameter of 28.9 (5.8) vs 24.4 (4.1) mm HR = 1.225, 95% CI = 1.028-1.460 per 1 mm, P = .016 were predictors of death. CONCLUSIONS Preoperative TTE parameters: right ventricular systolic pressure, tricuspid regurgitation pressure gradient, tricuspid annular plane systolic excursion, and pulmonary artery diameter predicted MCS use during LuTx. Certain values of valve acceleration time and pulmonary artery diameter could help discern LuTx qualification.
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Affiliation(s)
- Bartosz Kubisa
- Thoracic Surgery and Transplantation Department, Pomeranian Medical University of Szczecin, Szczecin, Poland.
| | - Anna Kubisa
- Internal Medicine Ward, SPWSZ Hospital Szczecin-Zdunowo, Szczecin, Poland
| | - Maria Piotrowska
- Thoracic Surgery and Transplantation Department, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Krzysztof Safranow
- Department of Biochemistry, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Tomasz Grodzki
- Thoracic Surgery and Transplantation Department, Pomeranian Medical University of Szczecin, Szczecin, Poland
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Trittmann JK, Almazroue H, Nelin LD, Shaffer TA, Celestine CR, Green HW, Malbrue RA. PATET ratio by Doppler echocardiography: noninvasive detection of pediatric pulmonary arterial hypertension. Pediatr Res 2022; 92:631-636. [PMID: 34795389 PMCID: PMC9114166 DOI: 10.1038/s41390-021-01840-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 10/09/2021] [Accepted: 10/28/2021] [Indexed: 11/12/2022]
Abstract
Pulmonary artery acceleration time (PAT) and PAT: ejection time (PATET) ratio are echocardiographic measurements of pulmonary arterial hypertension (PAH). These noninvasive quantitative measurements are ideal to follow longitudinally through the clinical course of PAH, especially as it relates to the need for and/or response to treatment. This review article focuses on the current literature of PATET measurement for infants and children as it relates to the shortening of the PATET ratio in PAH. At the same time, further development of PATET as an outcome measure for PAH in preclinical models, particularly mice, such that the field can move forward to human clinical studies that are both safe and effective. Here, we present what is known about PATET in infants and children and discuss what is known in preclinical models with particular emphasis on neonatal mouse models. In both animal models and human disease, PATET allows for longitudinal measurements in the same individual, leading to more precise determinations of disease/model progression and/or response to therapy. IMPACT: PATET ratio is a quantitative measurement by a noninvasive technique, Doppler echocardiography, providing clinicians a more precise/accurate, safe, and longitudinal assessment of pediatric PAH. We present a brief history/state of the art of PATET ratio to predict PAH in adults, children, infants, and fetuses, as well as in small animal models of PAH. In a preliminary study, PATET shortened by 18% during acute hypoxic exposure compared to pre-hypoxia. Studies are needed to establish PATET, especially in mouse models of disease, such as bronchopulmonary, as a routine measure of PAH.
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Affiliation(s)
- Jennifer K. Trittmann
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH,Department of Pediatrics, The Ohio State University, College of Medicine, Columbus, OH,Jennifer K. Trittmann, MD, MPH, Center for Perinatal Research, Abigail Wexner Research Institute at, Nationwide Children’s Hospital and, The Ohio State University, College of Medicine, Columbus, OH, USA,
| | - Hanadi Almazroue
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Leif D. Nelin
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH,Department of Pediatrics, The Ohio State University, College of Medicine, Columbus, OH
| | - Terri A. Shaffer
- Animal Resources Core, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Charanda R. Celestine
- Louisiana State University, School of Veterinary Medicine, Department of Veterinary Clinical Sciences, Baton Rouge, LA, USA
| | - Henry W. Green
- Louisiana State University, School of Veterinary Medicine, Department of Veterinary Clinical Sciences, Baton Rouge, LA, USA
| | - Raphael A. Malbrue
- Animal Resources Core, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH,The Ohio State University, College of Veterinary Medicine, Columbus, OH
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14
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Tai C, Hsieh A, Moon-Grady AJ, Keller RL, Teitel D, Nawaytou HM. Pulmonary artery acceleration time in young children is determined by heart rate and transpulmonary gradient but not by pulmonary blood flow: A simultaneous echocardiography-cardiac catheterization study. Echocardiography 2022; 39:895-905. [PMID: 35690918 DOI: 10.1111/echo.15397] [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: 10/26/2021] [Revised: 04/06/2022] [Accepted: 05/21/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Pulmonary artery acceleration time (PAAT) is considered useful for the non-invasive evaluation of pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR). PAAT is dependent on PAP, PVR, pulmonary artery compliance, stroke volume, and heart rate. Its relative dependency on these determinants may differ between young and older children, raising uncertainty regarding its utility in young children. We aim to identify the primary determinants of the PAAT in children less than 36 months undergoing cardiac catheterization and its utility for the diagnosis of elevated PVR. METHODS We prospectively studied 42 children undergoing cardiac catheterization and simultaneous echocardiography. We determined the correlations of PAAT to the above-mentioned determinants and evaluated receiver operator characteristic (ROC) curves for diagnosis of PVR indexed to body surface area (PVRi) ≥3 Wu*m2 . RESULTS Median age was 11.5 (IQR 5.2, 21.2) months. Moderate correlations were found between PAAT and mean PAP (R = -.66, p < .001), PVRi (R = -.54, p = .004), pulmonary artery compliance (R = .65, p < .001), transpulmonary gradient (R = -.67, p < .001), stroke volume (R = .61, p = .002), and heart rate (R = -.63, p < .001). In multivariate regression modeling, only transpulmonary gradient and heart rate were independent determinants of PAAT. PAAT ≤77 msec had acceptable utility for diagnosing PVRi ≥ 3 Wu*m2 (AUC .8 [.64, .95], n = 36), low sensitivity (59%), and excellent specificity (94%). CONCLUSION Transpulmonary gradient and heart rate, but not pulmonary blood flow, are important determinants of PAAT in children <36 months undergoing cardiac catheterization. PAAT has low sensitivity for diagnosing elevated PVRi, therefore, should not be solely relied upon in screening for elevated PVRi in young children.
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Affiliation(s)
- Christiana Tai
- Department of Pediatrics, University of California, San Francisco, California, USA
| | - Anyir Hsieh
- Department of Pediatrics, University of California, San Francisco, California, USA
| | - Anita J Moon-Grady
- Department of Pediatrics, University of California, San Francisco, California, USA
| | - Roberta L Keller
- Department of Pediatrics, University of California, San Francisco, California, USA
| | - David Teitel
- Department of Pediatrics, University of California, San Francisco, California, USA
| | - Hythem M Nawaytou
- Department of Pediatrics, University of California, San Francisco, California, USA
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15
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Carpenter RJ, Srdanovic N, Rychlik K, Sen SK, Porta NFM, Hamvas AE, Murthy K, Hauck AL. The association between pulmonary vascular disease and respiratory improvement in infants with type I severe bronchopulmonary dysplasia. J Perinatol 2022; 42:788-795. [PMID: 35397644 DOI: 10.1038/s41372-022-01386-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 03/14/2022] [Accepted: 03/25/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe the association between echocardiographic measures of pulmonary vascular disease and time to respiratory improvement among infants with Type I severe bronchopulmonary dysplasia (sBPD). STUDY DESIGN We measured the pulmonary artery acceleration time indexed to the right ventricular ejection time (PAAT/RVET) and right ventricular free wall longitudinal strain (RVFWLS) at 34-41 weeks' postmenstrual age. Cox-proportional hazards models were used to estimate the relationship between the PAAT/RVET, RVFWLS, and the outcome: days from 36 weeks' postmenstrual age to room-air or discharge with oxygen (≤0.5 L/min). RESULT For 102 infants, the mean PAAT/RVET and RVFWLS were 0.27 ± 0.06 and -22.63 ± 4.23%. An abnormal measurement was associated with an increased time to achieve the outcome (PAAT/RVET: 51v24, p < 0.0001; RVFWLS; 62v38, p = 0.0006). A normal PAAT/RVET was independently associated with a shorter time to outcome (aHR = 2.04, 1.11-3.76, p = 0.02). CONCLUSION The PAAT/RVET may aid in anticipating timing of discharge in patients with type I severe BPD.
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Affiliation(s)
- Ryan J Carpenter
- Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Nina Srdanovic
- Biostatistics Collaboration Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Karen Rychlik
- Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Shawn K Sen
- Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Nicolas F M Porta
- Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Aaron E Hamvas
- Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Karna Murthy
- Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Amanda L Hauck
- Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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sPAP/PAAT Ratio as a New Index of Pulmonary Vascular Load: A Study in Normal Subjects and Ssc Patients with and without PH. PATHOPHYSIOLOGY 2022; 29:134-142. [PMID: 35366295 PMCID: PMC8949923 DOI: 10.3390/pathophysiology29010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/02/2022] [Accepted: 03/08/2022] [Indexed: 11/17/2022] Open
Abstract
In pulmonary hypertension (PH), the development of right ventricular (RV) dilatation and RV failure are signs of accelerated progression of the disease, resulting in an increased risk of cardiac death. Even the noninvasive assessment of systolic blood pressure in the pulmonary artery undertaken by echocardiography does not provide a measure of ventricle–pulmonary interaction. Some studies have shown the potential for echocardiography to indirectly evaluate pulmonary vascular resistance (PVR) and the acceleration time of pulmonary outflow (PAAT). We used systolic pulmonary artery pressure (sPAP) and pulmonary vascular resistance to develop an sPAP/PAAT ratio (strength/surface unit)/(time) for this study. From January 2017 to December 2018, 60 healthy subjects and 63 patients with systemic scleroderma (Ssc) (60 females, 3 males), 27 with PH and 36 without PH at two-dimensional echocardiographic/Doppler, were screened. In normal subjects, the mean sPAP/PAAT ratio was 0.26 ± 0.063, which indicated optimal pulmonary arterial ventricle coupling and biventricular function. The data derived from the analysis of the Ssc patients showed that those presenting pre-capillary PH at cardiac catheterization had an sPAP/PAAT ratio of 0.40 ± 0.05. There was a significant correlation between sPAP/PAAT with Walk Distance (WD) and PVR, but not with TAPSE. Interobserver variability was less than 5%. The sPAP/PAAT ratio is a new parameter that may indicate pulmonary vascular afterload and interaction, both in normal subjects and in patients with Ssc and PH.
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17
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Chen D, Yuan T, Chen Y, Zhang H, Niu Z, Fang L, Du G. DL0805-1, a novel Rho-kinase inhibitor, attenuates lung injury and vasculopathy in a rat model of monocrotaline-induced pulmonary hypertension. Eur J Pharmacol 2022; 919:174779. [DOI: 10.1016/j.ejphar.2022.174779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/17/2022] [Accepted: 01/24/2022] [Indexed: 11/03/2022]
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Alerhand S, Sundaram T, Gottlieb M. What are the echocardiographic findings of acute right ventricular strain that suggest pulmonary embolism? Anaesth Crit Care Pain Med 2021; 40:100852. [PMID: 33781986 DOI: 10.1016/j.accpm.2021.100852] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/24/2020] [Accepted: 01/13/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Pulmonary embolism (PE) is a potentially fatal disease encountered in the hospital setting. Prompt diagnosis and management can improve outcomes and survival. Unfortunately, a PE may be difficult to diagnose in a timely manner. Point-of-care ultrasound (POCUS) can assist in the evaluation for suspected PE by assessing for acute right ventricular strain. Physicians should thus be aware of these echocardiographic findings. OBJECTIVE This manuscript will review ten echocardiographic findings of right ventricular strain that may suggest a diagnosis of PE. It will provide a description of each finding along with the associated pathophysiology. It will also summarize the literature for the diagnostic utility of echocardiography for this indication, while providing reference parameters where applicable. Along with labeled images and video clips, the review will then illustrate how to evaluate for each of the ten findings, while offering pearls and pitfalls in this bedside evaluation. DISCUSSION The ten echocardiographic findings of right ventricular strain are: increased right ventricle: left ventricle size ratio, abnormal septal motion, McConnell's sign, tricuspid regurgitation, elevated pulmonary artery systolic pressure, decreased tricuspid annular plane systolic excursion, decreased S', pulmonary artery mid-systolic notching, 60/60 sign, and speckle tracking demonstrating decreased right ventricular free wall strain. CONCLUSIONS Physicians must recognize and understand the echocardiographic findings and associated pathophysiology of right ventricular strain. In the proper clinical context, these findings can point toward a diagnosis of PE and thereby lead to earlier initiation of directed management.
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Affiliation(s)
- Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, 150 Bergen Street, Newark, NJ 07103, USA.
| | - Tina Sundaram
- Department of Emergency Medicine, Rush University Medical Center, 1750 W. Harrison Street, Kellogg Suite 108, Chicago, IL 60612, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, 1750 W. Harrison Street, Kellogg Suite 108, Chicago, IL 60612, USA
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F Zaky A, Froelich M, Meers B, Sturdivant AB, Densmore R, Subramaniam A, Carter T, Tita AN, Matalon S, Jilling T. Noninvasive Assessment of Right Ventricle Function and Pulmonary Artery Pressure Using Transthoracic Echocardiography in Women With Pre-Eclampsia: An Exploratory Study. Cureus 2021; 13:e13419. [PMID: 33763315 PMCID: PMC7980723 DOI: 10.7759/cureus.13419] [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] [Indexed: 11/05/2022] Open
Abstract
Background and objective Pre-eclampsia (PEC) is associated with the release of anti-angiogenic factors that are incriminated in raising systemic and pulmonary vascular resistance (PVR). Compared to the left heart and systemic circulation, much less attention has been paid to the right heart and pulmonary circulation in patients with PEC. We used transthoracic echocardiography (TTE) to estimate pulmonary artery (PA) pressure and right ventricular (RV) function in women with PEC. Materials and methods We conducted a case-control study at a tertiary care academic center. Ten early PEC (<34-week gestation) and nine late PEC (≥34-week gestation) patients with 11 early and 10 late gestational age-matched controls were enrolled. Two-dimensional TTE was performed on all patients. The estimated mean PA pressure (eMPAP) was calculated based on PA acceleration time (PAAT). PVR was estimated from eMPAP and RV cardiac output (RV CO). RV myocardial performance index (RV MPI), tricuspid annular plane systolic excursion (TAPSE), tissue tricuspid annular displacement (TTAD), and lateral tricuspid annular tissue peak systolic velocity (S’) were measured. Results Compared to early controls, in early PEC, the eMPAP and estimated PVR (ePVR) were elevated, PAAT was reduced, RV MPI was increased, TTAD was reduced, and TAPSE and TV S’ were unchanged. Compared to late controls, in late PEC, the eMPAP and ePVR were elevated, PAAT was reduced, and RV MPI was increased, while TAPSE, TTAD, and TV S’ were unchanged. Conclusions In a sample of women with PEC, early PEC was found to be associated with increased eMPAP and ePVR and subclinical decrement of RV function as assessed by TTE. TTE may be a useful noninvasive screening tool for early detection of pulmonary hypertension and RV dysfunction in PEC. An adequately powered longitudinal study is needed to determine the implications of these findings on long-term outcomes.
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Affiliation(s)
- Ahmed F Zaky
- Anesthesiology, University of Alabama at Birmingham, Birmingham, USA
| | - Michael Froelich
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, USA
| | - Brad Meers
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Adam B Sturdivant
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, USA
| | | | - Akila Subramaniam
- Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, USA
| | - Tekuila Carter
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Alan N Tita
- Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, USA
| | - Sadis Matalon
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Tamas Jilling
- Pediatrics, University of Alabama at Birmingham, Birmingham, USA
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Kim KK, Krause M, Brandes IF, Khanna AK, Bartels K. Transesophageal echocardiography for perioperative management in thoracic surgery. Curr Opin Anaesthesiol 2021; 34:7-12. [PMID: 33315644 DOI: 10.1097/aco.0000000000000947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW Perioperative transesophageal echocardiography (TEE) is most often employed during cardiac surgery. This review will summarize some of the recent findings relevant to TEE utilization during thoracic surgical procedures. RECENT FINDINGS Hemodynamic monitoring is a key component of goal-directed fluid therapy, which is also becoming more common for management of thoracic surgical procedures. Although usually not required for the anesthetic management of common thoracic surgeries, TEE is frequently used during lung transplantation and pulmonary thromboendarterectomy. Few clinical studies support current practice patterns, and most recommendations are based on expert opinion. SUMMARY Currently, routine use of TEE in thoracic surgery is often limited to specific high-risk patients and/or procedures. As in other perioperative settings, TEE may be utilized to elucidate the reasons for acute hemodynamic instability without apparent cause. Contraindications to TEE apply and have to be taken into consideration before performing a TEE on a thoracic surgical patient.
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Affiliation(s)
- Kevin K Kim
- Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Martin Krause
- Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Ivo F Brandes
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University, School of Medicine, Winston-Salem, North Carolina, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Karsten Bartels
- Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado, USA
- Outcomes Research Consortium, Cleveland, OH, USA
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Pestelli G, Fiorencis A, Trevisan F, Luisi GA, Smarrazzo V, Mele D. New measures of right ventricle-pulmonary artery coupling in heart failure: An all-cause mortality echocardiographic study. Int J Cardiol 2021; 329:234-241. [PMID: 33359279 DOI: 10.1016/j.ijcard.2020.12.057] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 12/06/2020] [Accepted: 12/14/2020] [Indexed: 11/27/2022]
Abstract
AIMS Right ventricle-pulmonary artery coupling (RVPAC) has emerged from pathophysiology to clinical interest for prognostic implication in heart failure and is commonly measured as the ratio between tricuspid annular plane systolic excursion and systolic pulmonary artery pressure (TAPSE/SPAP). However, feasibility of SPAP is limited (down to 60% in trials, and maybe lower in clinical practice). We ought to assess the prognostic value of the TAPSE times pulmonary acceleration time (TAPSE x pACT) product and TAPSE to peak tricuspid regurgitation velocity (TAPSE/TRV) ratio as new alternative measures of RVPAC. METHODS AND RESULTS Two-hundred patients hospitalized with heart failure were followed-up (median time of 2.7 years) and 82 died. Non survivors had significantly lower TAPSE/SPAP, TAPSE x pACT and TAPSE/TRV than survivors (0.31 vs 0.40 mm/mmHg, 130 vs 156 cm·ms, 5.0 vs 5.8 ms, respectively). Four multivariate models were performed, each one including TAPSE, TAPSE/SPAP, TAPSE x pACT or TAPSE/TRV. TAPSE/SPAP resulted the most powerful predictor of mortality (HR 0.74 per mm/mmHg increase, P < 0.001, C-Statistic 0.778), followed by TAPSE x pACT (HR 0.95 per 10 cm·ms increase, P = 0.013, C-Statistic 0.776), TAPSE/TRV (HR 0.76 per ms increase, P < 0.001, C-Statistic 0.774) and TAPSE (HR 0.91 per mm increase, P = 0.003, C-Statistic 0.769). Cutoff values of 140 cm·ms and 5.5 ms were respectively identified for TAPSE x pACT and TAPSE/TRV with receiving operating characteristic analysis for mortality. CONCLUSION TAPSE x pACT product and TAPSE/TRV ratio are alternative measures of RVPAC for prognostic assessment in heart failure that can be applied if TAPSE/SPAP is not feasible.
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Affiliation(s)
- Gabriele Pestelli
- Cardiology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy; Cardiovascular Research Unit, Fondazione Sacco, Forlì, Italy
| | | | | | | | | | - Donato Mele
- Cardiology Unit, University Hospital of Ferrara, Ferrara, Italy.
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Wierzbowska-Drabik K, Picano E, Bossone E, Ciampi Q, Lipiec P, Kasprzak JD. The feasibility and clinical implication of tricuspid regurgitant velocity and pulmonary flow acceleration time evaluation for pulmonary pressure assessment during exercise stress echocardiography. Eur Heart J Cardiovasc Imaging 2020; 20:1027-1034. [PMID: 30824900 DOI: 10.1093/ehjci/jez029] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 02/13/2019] [Indexed: 11/13/2022] Open
Abstract
AIMS Echocardiography can estimate pulmonary arterial pressure (PAP) from tricuspid regurgitation velocity (TRV) or acceleration time (ACT) of pulmonary flow. We assessed the feasibility of TRV and ACT measurements during exercise stress echocardiography (ESE) and their correlation in all stages of ESE. METHODS AND RESULTS We performed ESE in 102 subjects [mean age 49 ± 17 years, 50 females, 39 healthy, 30 with cardiovascular risk factors, and 33 with pulmonary hypertension (PH)] referred for the assessment of exercise tolerance and ischaemia exclusion. ESE was performed on cycloergometer with the load increasing by 25 W for each 2 min. Assessment of TRV with continuous wave and ACT with pulsed Doppler were attempted in 306 time points: at rest, peak exercise, and recovery. In 20 PH patients we evaluated the correlations of TRV and ACT with invasively measured PAP. The success rate was 183/306 for TRV and 304/306 for ACT (feasibility: 60 vs. 99%, P < 0.0001). There was a close correlation between TRV and ACT: r = 0.787, P < 0.001 and ACT at peak ≤67 ms showed 94% specificity for elevated systolic PAP detection. Moreover, TRV and ACT at peak exercise reflected better that resting data the invasive systolic PAP and mean PAP with r = 0.76, P = 0.0004 and r = -0.67, P = 0.0018, respectively. CONCLUSION ACT is closely correlated with and substantially more feasible than TRV during ESE and inclusion of both parameters (TRACT approach) expands the possibility of PAP assessment, especially at exercise when TRV feasibility is the lowest but correlation with invasive PAP seems to increase.
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Affiliation(s)
- Karina Wierzbowska-Drabik
- Department of Cardiology, Medical University of Lodz, Bieganski Hospital, Ul. Kniaziewicza 1/5, 91-347 Lodz, Poland
| | - Eugenio Picano
- Institute of Clinical Physiology, National Council Research, Via Giuseppe Moruzzi 1, Pisa 56124, Italy
| | - Eduardo Bossone
- Echo-Lab, Division of Cardiology, Internal Medicine Department, AORN A. Cardarelli Hospital, Via A. Cardarelli 9, 80131 Naples, Italy
| | - Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, Viale Principe di Napoli, 12, 82100 Benevento, Italy
| | - Piotr Lipiec
- Department of Cardiology, Medical University of Lodz, Bieganski Hospital, Ul. Kniaziewicza 1/5, 91-347 Lodz, Poland
| | - Jarosław Damian Kasprzak
- Department of Cardiology, Medical University of Lodz, Bieganski Hospital, Ul. Kniaziewicza 1/5, 91-347 Lodz, Poland
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Echocardiographic Assessment of Right Ventricular Afterload in Preterm Infants: Maturational Patterns of Pulmonary Artery Acceleration Time Over the First Year of Age and Implications for Pulmonary Hypertension. J Am Soc Echocardiogr 2020; 32:884-894.e4. [PMID: 31272593 DOI: 10.1016/j.echo.2019.03.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 03/20/2019] [Accepted: 03/20/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Assessment of pulmonary hemodynamics is critical in the diagnosis and management of cardiopulmonary disease of premature infants, but reliable noninvasive indices of pulmonary hemodynamics in preterm infants are lacking. Because pulmonary artery acceleration time (PAAT) is a validated noninvasive method to assess right ventricular (RV) afterload in infants and children, the aim of this study was to investigate the maturational changes of PAAT measures in preterm infants over the first year of age and to discern the impact of typical cardiopulmonary abnormalities on these measures. METHODS In a prospective multicenter study of 239 preterm infants (<29 weeks at birth), PAAT was assessed at days 1, 2, and 5 to 7, at 32 and 36 weeks' postmenstrual age, and at 1-year corrected age. To account for heart rate variability, PAAT was adjusted for RV ejection time. Premature infants who developed bronchopulmonary dysplasia or had echocardiographic findings of pulmonary hypertension were analyzed separately. Intra- and interobserver reproducibility analysis was performed. RESULTS PAAT was feasible in 95% of the image acquisitions, and there was high intra- and interobserver agreement (intraclass correlation coefficients > 0.9 and coefficients of variation < 6%). In uncomplicated preterm infants (n = 103 [48%]) PAAT and PAAT adjusted for RV ejection time increased longitudinally from birth to 1-year corrected age (P < .001) and were linearly associated with gestational age at birth (r = 0.81 and r = 0.82, P < .001) and increasing postnatal weight and postnatal age (r > 0.81, P < .001). PAAT measures were significantly reduced (P < .001) in infants with bronchopulmonary dysplasia and/or pulmonary hypertension (n = 119 [51%]) beyond 1 week of age. CONCLUSIONS PAAT measures increase in preterm infants from birth to 1-year corrected age, reflective of the physiologic postnatal drop in RV afterload. Bronchopulmonary dysplasia and pulmonary hypertension have a negative impact on PAAT measures. By demonstrating excellent reliability and establishing reference patterns of PAAT in preterm infants, this study suggests that PAAT and PAAT adjusted for RV ejection time can be used as complementary parameters to assess physiologic and pathologic changes in pulmonary hemodynamics in neonates.
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Wierzbowska-Drabik K, Kasprzak JD, D Alto M, Ágoston G, Varga A, Ferrara F, Amor M, Ciampi Q, Bossone E, Picano E. Reduced pulmonary vascular reserve during stress echocardiography in confirmed pulmonary hypertension and patients at risk of overt pulmonary hypertension. Int J Cardiovasc Imaging 2020; 36:1831-1843. [PMID: 32462450 PMCID: PMC7497494 DOI: 10.1007/s10554-020-01897-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 05/21/2020] [Indexed: 12/19/2022]
Abstract
Noninvasive estimation of systolic pulmonary artery pressure (SPAP) during exercise stress echocardiography (ESE) is recommended for pulmonary hemodynamics evaluation but remains flow-dependent. Our aim was to assess the feasibility of pulmonary vascular reserve index (PVRI) estimation during ESE combining SPAP with cardiac output (CO) or exercise-time and compare its value in three group of patients: with invasively confirmed pulmonary hypertension (PH), at risk of PH development (PH risk) mainly with systemic sclerosis and in controls (C) without clinical risk factors for PH, age-matched with PH risk patients. We performed semisupine ESE in 171 subjects: 31 PH, 61 PH at risk and 50 controls as well as in 29 young, healthy normals. Rest and stress assessment included: tricuspid regurgitant flow velocity (TRV), pulmonary acceleration time (ACT), CO (Doppler-estimated). SPAP was calculated from TRV or ACT when TRV was not available. We estimated PVRI based on CO (peak CO/SPAP*0.1) or exercise-time (ESE time/SPAP*0.1). During stress, TRV was measurable in 44% patients ACT in 77%, either one in 95%. PVRI was feasible in 65% subjects with CO and 95% with exercise-time (p < 0.0001). PVRI was lower in PH compared to controls both for CO-based PVRI (group 1 = 1.0 ± 0.95 vs group 3 = 4.28 ± 2.3, p < 0.0001) or time-based PVRI estimation (0.66 ± 0.39 vs 3.95 ± 2.26, p < 0.0001). The proposed criteria for PH detection were for CO-based PVRI ≤ 1.29 and ESE-time based PVRI ≤ 1.0 and for PH risk ≤ 1.9 and ≤ 1.7 respectively. Noninvasive estimation of PVRI can be obtained in near all patients during ESE, without contrast administration, integrating TRV with ACT for SPAP assessment and using exercise time as a proxy of CO. These indices allow for comparison of pulmonary vascular dynamics in patients with varied exercise tolerance and clinical status.
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Affiliation(s)
| | - Jarosław D Kasprzak
- I Department and Chair of Cardiology, Medical University of Lodz, Bieganski Hospital, Lodz, Poland
| | - Michele D Alto
- Department of Cardiology, University "L. Vanvitelli"- AORN dei Colli - Monaldi Hospital, Naples, Italy
| | - Gergely Ágoston
- Department of Family Medicine, University of Szeged, Tisza Lajos krt. 109, Szeged, 6725, Hungary
| | - Albert Varga
- Department of Family Medicine, University of Szeged, Tisza Lajos krt. 109, Szeged, 6725, Hungary
| | - Francesco Ferrara
- Cardiology Division, Heart Department, University Hospital of Salerno, "Cava de' Tirreni and Amalfi Coast" Hospital, Salerno, Italy
| | - Miguel Amor
- Cardiology Department, Ramos Mejia Hospital, Buenos Aires, Argentina
| | - Quirino Ciampi
- Division of Cardiology, Fatebenefratelli Hospital, Benevento, Italy
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Mele D, Pestelli G, Dini FL, Dal Molin D, Smarrazzo V, Trevisan F, Luisi GA, Ferrari R. Novel Echocardiographic Approach to Hemodynamic Phenotypes Predicts Outcome of Patients Hospitalized With Heart Failure. Circ Cardiovasc Imaging 2020; 13:e009939. [PMID: 32312116 DOI: 10.1161/circimaging.119.009939] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although in clinical practice heart failure (HF) patients are classified using left ventricular ejection fraction (LVEF), this categorization is insufficient for prognosis, especially when LVEF is preserved or there is a concomitant right ventricular (RV) dysfunction. We hypothesized that a combined noninvasive evaluation of LV forward flow, filling pressure, and RV function would be better than LVEF in predicting all-cause mortality of hospitalized patients with HF. METHODS Transthoracic echocardiographic examinations of 603 patients hospitalized with HF were analyzed. In a subsample of 200 patients with HF, LV stroke volume index, LV filling pressure estimation, tricuspid annular plane systolic excursion, and systolic pulmonary artery pressure were combined to determine 4 hemodynamic profiles: normal flow-normal pressure, normal flow-high pressure, low flow without RV dysfunction, and low flow with RV dysfunction profile. This model was then applied in a validation cohort (n=403). RESULTS Prognosis worsened from the normal flow-normal pressure profile to the low flow with right ventricular dysfunction profile. At the multivariate survival analysis, the model showed independent high risk-stratification capability (P<0.001), even in subgroups of patients with LVEF < or ≥50% (P=0.011 and P<0.001, respectively) and < or ≥40% (P=0.044 and P<0.001, respectively). LVEF and HF classification based on LVEF did not predict outcome. CONCLUSIONS Echocardiographic-derived profiling of LV forward flow, filling pressure, and RV function allowed categorization of patients hospitalized with HF and predicted all-cause mortality independently of LVEF. This model is based on conventional echocardiography, is easy to apply, and is, therefore, suggested for clinical practice.
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Affiliation(s)
- Donato Mele
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Gabriele Pestelli
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Frank Lloyd Dini
- Cardiovascular Diseases Unit 1, Cardiovascular and Thoracic Department, University of Pisa, Italy (F.L.D.)
| | - Davide Dal Molin
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Vittorio Smarrazzo
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Filippo Trevisan
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Giovanni Andrea Luisi
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Roberto Ferrari
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.).,Maria Cecilia Hospital, GVM Care & Research, E.S. Health Science Foundation, Cotignola (RA), Italy (R.F.)
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Moreira HT, Vasconcellos HD, Ambale-Venkatesh B, Brittain EL, Nwabuo CC, Schmidt A, Lloyd-Jones DM, Carr JJ, Lewis CE, Jacobs DR, Gidding SS, Lima JAC. Pulmonary Artery Acceleration Time in Young Adulthood and Cardiovascular Outcomes Later in Life: The Coronary Artery Risk Development in Young Adults Study. J Am Soc Echocardiogr 2020; 33:82-89.e1. [PMID: 31648849 DOI: 10.1016/j.echo.2019.07.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/14/2019] [Accepted: 07/16/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Lower pulmonary artery acceleration time (PAcT) is correlated with higher pulmonary artery pressure. The aim of this study was to test the hypothesis that PAcT measured in young adulthood would be associated with future cardiovascular outcomes. METHODS In the Coronary Artery Risk Development in Young Adults year 5 examination (1990-1991), PAcT was measured as the time interval from onset to peak flow velocity at the pulmonary valve annulus on Doppler echocardiography. The primary outcome was a composite of fatal or nonfatal cardiovascular disease events: myocardial infarction, non-myocardial infarction acute coronary syndrome, coronary revascularization, congestive heart failure, stroke, transient ischemic attack, carotid artery disease, and peripheral arterial disease. RESULTS PAcT was obtained in 4,171 participants (mean age, 30 ± 4 years, 55% women, 51% white). PAcT groups obtained using linear spline methodology were as follows: group I, PAcT ≥ 196 msec (n = 122); group II, PAcT < 196 and ≥115 msec (n = 3,195); and group III, PAcT < 115 msec (n = 854). During follow-up (median, 24.9 years), the primary outcome occurred in 216 participants (5.2%); 66 of 854 (7.7%) of those with PAcT < 115 msec, 149 of 3,195 (4.7%) of those with intermediate PAcT level, and one of 122 (0.8%) of those with PAcT ≥ 196 msec. In a fully adjusted model, the lowest and intermediate PAcT groups had hazard ratios of 8.3 (95% CI, 1.1-62.1; P = .04) and 6.8 (95% CI, 0.9-50.5; P = .06), respectively, in comparison with the highest PAcT group. CONCLUSIONS PAcT is useful for better identifying young adults at higher risk for cardiovascular events, who may benefit from a strict control of modifiable cardiovascular risk factors.
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Affiliation(s)
- Henrique T Moreira
- Johns Hopkins University, Baltimore, Maryland; University of São Paulo, Ribeirão Preto, Brazil
| | | | | | | | | | | | | | - John J Carr
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cora E Lewis
- University of Alabama at Birmingham, Birmingham, Alabama
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Gaulton JS, Mercer-Rosa LM, Glatz AC, Jensen EA, Capone V, Scott C, Appel SM, Stoller JZ, Fraga MV. Relationship between pulmonary artery acceleration time and pulmonary artery pressures in infants. Echocardiography 2019; 36:1524-1531. [PMID: 31260138 DOI: 10.1111/echo.14430] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 05/28/2019] [Accepted: 06/11/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Pulmonary artery acceleration time measured by echocardiography inversely correlates with pulmonary artery pressures in adults and children older than 1 year of age. There is a paucity of data investigating this relationship in young children, particularly among preterm infants. OBJECTIVE To characterize the relationship between pulmonary artery acceleration time (PAAT) and pulmonary artery pressures in infants. DESIGN/METHODS Patients ≤ 1 year of age at Children's Hospital of Philadelphia between 2011 and 2017 were reviewed. Infants with congenital heart disease were excluded, except those with a patent ductus arteriosus (PDA), atrial septal defect (ASD), or ventricular septal defect (VSD). Linear regression analysis was used to assess the correlation between PAAT measured by echocardiography and systolic pulmonary artery pressure, mean pulmonary artery pressure, and indexed pulmonary vascular resistance from cardiac catheterization. RESULTS Fifty-seven infants were included, of which 61% were preterm and 49% had a diagnosis of bronchopulmonary dysplasia. The median postmenstrual age and weight at catheterization were 51.1 weeks (IQR 35.8-67.9 weeks) and 4400 g (IQR 3100-6500 g), respectively. Forty-four infants (77%) had a patent ductus arteriosus (PDA). There was a weak inverse correlation between PAAT with mPAP (r = -0.35, P = 0.01), sPAP (r = -0.29, P = 0.03), and PVRi (r = -0.29, P = 0.03). CONCLUSION There is a weak inverse relationship between PAAT and pulmonary artery pressures. This relationship is less robust in our population of infants with a high incidence of PDAs compared to previous studies in older children. Thus, PAAT may be less clinically meaningful for diagnosing pulmonary arterial hypertension in infants, particularly those with PDAs.
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Affiliation(s)
- Jessica S Gaulton
- Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Laura M Mercer-Rosa
- Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Erik A Jensen
- Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Valerie Capone
- Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Courtney Scott
- Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Scott M Appel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason Z Stoller
- Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - María V Fraga
- Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Choi JS, Lee SH, Leem AY, Song JH, Chung KS, Jung JY, Kang YA, Park MS, Kim YS, Chang J, Kim SY. Prognostic impact of the ratio of the main pulmonary artery to that of the aorta on chest computed tomography in patients with idiopathic pulmonary fibrosis. BMC Pulm Med 2019; 19:81. [PMID: 30999878 PMCID: PMC6472007 DOI: 10.1186/s12890-019-0843-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 04/02/2019] [Indexed: 11/10/2022] Open
Abstract
Background In many clinical disorders, there is a relationship between the ratio of the diameter of the main pulmonary artery (mPA) to that of the aorta (Ao) on chest computed tomography (CT). The aim of this study was to determine if the mPA/Ao ratio at diagnosis is associated with the clinical characteristics and outcomes in patients with idiopathic pulmonary fibrosis (IPF). Methods We retrospectively reviewed the diameters of the pulmonary artery and aorta on chest CT, clinical characteristics, and results of other examinations in 303 patients at the time of initial diagnosis of IPF at our tertiary care center between 2011 and 2015. The primary outcomes were death and lung transplantation. The patients were followed up until June 2017. Results One hundred and eight patients (35.6%) died and 58 (19.1%) underwent lung transplantation during follow-up. The mean mPA and Ao diameters were 28.3 mm and 34.0 mm, respectively, and the mean mPA/Ao ratio was 0.84. Thirty-one patients (10.2%) had an mPA/Ao ratio > 1.0 and 182 (60.1%) had an mPA/Ao ratio > 0.8. Patients with an mPA/Ao ratio > 0.8 had a lower DLco value than those with an mPA/Ao ratio ≤ 0.8. In Kaplan-Meier analysis, patients with an mPA/Ao ratio > 1.0 or > 0.8 had worse outcomes than those with an mPA/Ao ratio ≤ 1.0 and ≤ 0.8, respectively. Conclusions A higher mPA/Ao ratio based on 1.0 and 0.8 is associated with unfavorable prognosis in patients with IPF.
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Affiliation(s)
- Ji Soo Choi
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Sang Hoon Lee
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Ah Young Leem
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Joo Han Song
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Kyung Soo Chung
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Ji Ye Jung
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Young Ae Kang
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Moo Suk Park
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Young Sam Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Joon Chang
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Song Yee Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Thompson LC, Kim YH, Martin BL, Ledbetter AD, Dye JA, Hazari MS, Gilmour MI, Farraj AK. Pulmonary exposure to peat smoke extracts in rats decreases expiratory time and increases left heart end systolic volume. Inhal Toxicol 2019; 30:439-447. [PMID: 30642191 DOI: 10.1080/08958378.2018.1551443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Exposure to wildland fire-related particulate matter (PM) causes adverse health outcomes. However, the impacts of specific biomass sources remain unclear. The purpose of this study was to investigate cardiopulmonary responses in rats following exposure to PM extracts collected from peat fire smoke. We hypothesized that peat smoke PM would dose-dependently alter cardiopulmonary function. Male Sprague-Dawley rats (n = 8/group) were exposed to 35 µg (Lo PM) or 350 µg (Hi PM) of peat smoke PM extracts suspended in saline, or saline alone (Vehicle) via oropharyngeal aspiration (OA). Ventilatory expiration times, measured in whole-body plethysmographs immediately after OA, were the lowest in Hi PM exposed subjects at 6 min into recovery (p = .01 vs. Lo PM, p = .08 vs. Vehicle) and resolved shortly afterwards. The next day, we evaluated cardiovascular function in the same subjects via cardiac ultrasound under isoflurane anesthesia. Compared to Vehicle, Hi PM had 45% higher end systolic volume (p = .03) and 17% higher pulmonary artery blood flow acceleration/ejection time ratios, and both endpoints expressed significant increasing linear trends by dose (p = .01 and .02, respectively). In addition, linear trend analyses across doses detected an increase for end diastolic volume and decreases for ejection fraction and fractional shortening. These data suggest that exposure to peat smoke constituents modulates regulation of ventricular ejection and filling volumes, which could be related to altered blood flow in the pulmonary circulation. Moreover, early pulmonary responses to peat smoke PM point to irritant/autonomic mechanisms as potential drivers of later cardiovascular responses.
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Affiliation(s)
- Leslie C Thompson
- a US Environmental Protection Agency, Environmental Public Health Division , Durham , NC , USA
| | - Yong Ho Kim
- a US Environmental Protection Agency, Environmental Public Health Division , Durham , NC , USA.,b National Research Council , Washington , DC , USA
| | - Brandi L Martin
- c Oak Ridge Institute for Science and Education , Oak Ridge , TN , USA
| | - Allen D Ledbetter
- a US Environmental Protection Agency, Environmental Public Health Division , Durham , NC , USA
| | - Janice A Dye
- a US Environmental Protection Agency, Environmental Public Health Division , Durham , NC , USA
| | - Mehdi S Hazari
- a US Environmental Protection Agency, Environmental Public Health Division , Durham , NC , USA
| | - M Ian Gilmour
- a US Environmental Protection Agency, Environmental Public Health Division , Durham , NC , USA
| | - Aimen K Farraj
- a US Environmental Protection Agency, Environmental Public Health Division , Durham , NC , USA
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Echocardiographic Measurements of Right Ventricular Mechanics in Infants with Bronchopulmonary Dysplasia at 36 Weeks Postmenstrual Age. J Pediatr 2018; 203:210-217.e1. [PMID: 30244987 PMCID: PMC6252141 DOI: 10.1016/j.jpeds.2018.08.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 06/19/2018] [Accepted: 08/06/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To test the hypothesis that specific echocardiographic measurements of right ventricular (RV) mechanics at 36 weeks postmenstrual age (PMA) are associated with the severity of bronchopulmonary dysplasia (BPD). STUDY DESIGN A subset of 93 preterm infants (born between 27 and 29 weeks of gestation) was selected retrospectively from a prospectively enrolled cohort. BPD was defined using the National Institutes of Health workshop definition, with modifications for oxygen reduction testing and altitude. The cohort was divided into no-BPD and BPD groups using previously published methodology for analyses. Echocardiographic measurements of RV function (ie, tricuspid annular plane systolic excursion, fractional area of change, systolic-to-diastolic ratio, tissue Doppler myocardial performance index, and RV strain), RV remodeling/morphology (end-systolic left ventricular eccentricity index), and RV afterload (pulmonary artery acceleration time measure) were evaluated at 36 weeks PMA. Multivariable logistic regression determined associations between RV measurements and BPD severity. RESULTS Compared with the no-BPD cohort, the BPD group had lower birth weight z-scores (P = .04) and trended toward a male predominance (P = .08). After adjusting for birth weight z-score, gestational age, and sex, there were no between-group differences in echocardiographic measurements except for the eccentricity index (scaled OR [0.1-unit increase], 1.49; 95% CI, 1.13-2.12; P = .01). CONCLUSIONS Among conventional and emerging echocardiographic measurements of RV mechanics, eccentricity index was the sole variable independently associated with BPD severity in this study. The eccentricity index may be a useful echocardiographic measurement for characterizing RV mechanics in patients with BPD at 36 weeks PMA.
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Affiliation(s)
- Philip Thaler Levy
- Neonatology Washington University Medical School Pediatrics West Orange, New Jersey
| | - Meghna D Patel
- Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Gautam K Singh
- Neonatology, Washington University Medical School, Pediatrics, West Orange, New Jersey
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The effect of cold stress on right ventricular functions in patients with systemic sclerosis. MARMARA MEDICAL JOURNAL 2018. [DOI: 10.5472/marumj.472397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Picano E, Ciampi Q, Wierzbowska-Drabik K, Urluescu ML, Morrone D, Carpeggiani C. The new clinical standard of integrated quadruple stress echocardiography with ABCD protocol. Cardiovasc Ultrasound 2018; 16:22. [PMID: 30285774 PMCID: PMC6167852 DOI: 10.1186/s12947-018-0141-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/24/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The detection of regional wall motion abnormalities is the cornerstone of stress echocardiography. Today, stress echo shows increasing trends of utilization due to growing concerns for radiation risk, higher cost and stronger environmental impact of competing techniques. However, it has also limitations: underused ability to identify factors of clinical vulnerability outside coronary artery stenosis; operator-dependence; low positivity rate in contemporary populations; intermediate risk associated with a negative test; limited value of wall motion beyond coronary artery disease. Nevertheless, stress echo has potential to adapt to a changing environment and overcome its current limitations. INTEGRATED-QUADRUPLE STRESS-ECHO Four parameters now converge conceptually, logistically, and methodologically in the Integrated Quadruple (IQ)-stress echo. They are: 1- regional wall motion abnormalities; 2-B-lines measured by lung ultrasound; 3-left ventricular contractile reserve assessed as the stress/rest ratio of force (systolic arterial pressure by cuff sphygmomanometer/end-systolic volume from 2D); 4- coronary flow velocity reserve on left anterior descending coronary artery (with color-Doppler guided pulsed wave Doppler). IQ-Stress echo allows a synoptic functional assessment of epicardial coronary artery stenosis (wall motion), lung water (B-lines), myocardial function (left ventricular contractile reserve) and coronary small vessels (coronary flow velocity reserve in mid or distal left anterior descending artery). In "ABCD" protocol, A stands for Asynergy (ischemic vs non-ischemic heart); B for B-lines (wet vs dry lung); C for Contractile reserve (weak vs strong heart); D for Doppler flowmetry (warm vs cold heart, since the hyperemic blood flow increases the local temperature of the myocardium). From the technical (acquisition/analysis) viewpoint and required training, B-lines are the kindergarten, left ventricular contractile reserve the primary (for acquisition) and secondary (for analysis) school, wall motion the university, and coronary flow velocity reserve the PhD program of stress echo. CONCLUSION Stress echo is changing. As an old landline telephone with only one function, yesterday stress echo used one sign (regional wall motion abnormalities) for one patient with coronary artery disease. As a versatile smart-phone with multiple applications, stress echo today uses many signs for different pathophysiological and clinical targets. Large scale effectiveness studies are now in progress in the Stress Echo2020 project with the omnivorous "ABCD" protocol.
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Affiliation(s)
- Eugenio Picano
- Institute of Clinical Physiology, National Council Research, Via Giuseppe Moruzzi 1, 56124 Pisa, Italy
| | - Quirino Ciampi
- Fatebenefratelli Hospital of Benevento, Viale Principe di Napoli, 12, 82100 Benevento, Italy
| | - Karina Wierzbowska-Drabik
- Department of Cardiology, Medical University of Lodz, Bieganski Hospital, Ul Kniaziewicza 1/5, 91-347 Lodz, Poland
| | | | - Doralisa Morrone
- Cardiothoracic department, Cisanello Hospital, University of Pisa, Pisa, Italy
| | - Clara Carpeggiani
- Institute of Clinical Physiology, National Council Research, Via Giuseppe Moruzzi 1, 56124 Pisa, Italy
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Right Ventricular–Pulmonary Vascular Interactions: An Emerging Role for Pulmonary Artery Acceleration Time by Echocardiography in Adults and Children. J Am Soc Echocardiogr 2018; 31:962-964. [DOI: 10.1016/j.echo.2018.04.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Indexed: 12/19/2022]
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