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Ghio S, Badagliacca R, D'Alto M, Scelsi L, Argiento P, Brunetti ND, Casu G, Cedrone N, Confalonieri M, Corda M, Correale M, D'Agostino C, De Tommasi E, Filomena D, Galgano G, Greco A, Grimaldi M, Lombardi C, Madonna R, Manzi G, Mercurio V, Mihai A, Mulè M, Paciocco G, Papa S, Recchioni T, Romaniello A, Romeo E, Stolfo D, Vitulo P, Benza RL, Vizza CD. Right ventricular phenotyping in incident patients with idiopathic pulmonary arterial hypertension. J Heart Lung Transplant 2024; 43:1668-1676. [PMID: 38942159 DOI: 10.1016/j.healun.2024.06.003] [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: 04/12/2024] [Revised: 06/06/2024] [Accepted: 06/11/2024] [Indexed: 06/30/2024] Open
Abstract
BACKGROUND Right ventricular (RV) imaging has not a definite role in risk stratification of pulmonary arterial hypertension (PAH) patients. We tested the hypothesis that echocardiography-derived phenotypes, depicting different degrees of RV remodeling and dysfunction, may provide additional prognostic information to current risk stratification tools. METHODS Consecutive incident PAH patients aged ≥18 years, diagnosed between January 2005 and December 2021, underwent clinical assessment, right heart catheterization, standard echocardiography. Simple echocardiographic variables were combined in order to define a priori four phenotypes representing different degrees of RV dilatation and RV-pulmonary arterial (PA) coupling: Phenotype 1 with mildy dilated right ventricle and preserved RV-PA coupling (n = 152 patients); phenotype 2 with mildly dilated right ventricle and poor RV-PA coupling (n = 143 patients); phenotype 3 with severely dilated right ventricle and preserved RV-PA coupling (n = 201 patients); phenotype 4 with severely dilated right ventricle and poor RV-PA coupling, with or without severe tricuspid regurgitation (n = 519 patients). Risk stratification was based on the European Society of Cardiology/European Respiratory Society (ESC/ERS) 3-strata model and Registry to Evaluate Early and Long-Term PAH disease Management (REVEAL) 2.0 score. RESULTS These phenotypes were present in all risk groups. Notably, regardless of the ESC/ERS risk stratum assigned to the patient, phenotype 4 was associated with a 2-fold increase of the odds of death (HR 2.1, 95% CI 1.6-2.8, p < 0.001), while phenotype 1 was associated with a 71% reduction in the odds of dying (HR 0.29, 95% CI 0.18-0.47, p < 0.001). CONCLUSIONS Echocardiography-derived phenotypes describing RV remodeling and dysfunction may provide prognostic information which is independent of and additional to the clinically defined risk in incident PAH patients.
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Affiliation(s)
- Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico S Matteo, Pavia, Italy.
| | - Roberto Badagliacca
- Department of Clinical, Anesthesiological and Cardiovascular Sciences - Sapienza University of Rome, Rome, Italy
| | - Michele D'Alto
- Department of Cardiology, Monaldi Hospital - University "L. Vanvitelli", Naples, Italy
| | - Laura Scelsi
- Division of Cardiology, Fondazione IRCCS Policlinico S Matteo, Pavia, Italy
| | - Paola Argiento
- Department of Cardiology, Monaldi Hospital - University "L. Vanvitelli", Naples, Italy
| | - Natale D Brunetti
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Gavino Casu
- Division of Cardiology, Azienda Ospedaliero Universitaria, Sassari, Italy
| | - Nadia Cedrone
- Unità di Medicina Interna, Ospedale S. Pertini., Rome, Italy
| | - Marco Confalonieri
- Pulmonology Unit, Heart-Thorax-Vessels Dept., University Hospital of Cattinara, Trieste, Italy
| | - Marco Corda
- Cardiology Unit, Azienda Ospedaliera "G. Brotzu" San Michele, Cagliari, Italy
| | - Michele Correale
- Cardiology Department, Ospedali Riuniti University Hospital, Foggia, Italy
| | - Carlo D'Agostino
- Cardiology Department - University Hospital Policlinico Consorziale, Bari, Italy
| | | | - Domenico Filomena
- Department of Clinical, Anesthesiological and Cardiovascular Sciences - Sapienza University of Rome, Rome, Italy
| | - Giuseppe Galgano
- Department of Cardiology, "F.Miulli" Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Alessandra Greco
- Division of Cardiology, Fondazione IRCCS Policlinico S Matteo, Pavia, Italy
| | - Massimo Grimaldi
- Department of Cardiology, "F.Miulli" Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Carlo Lombardi
- Cardiologia, Università degli studi di Brescia, Brescia, Italy
| | - Rosalinda Madonna
- Cardiology Unit, Department of Surgical, Medical, Molecular Pathology and Critical Area Medicine, University of Pisa - UNIPI, Pisa, Italy
| | - Giovanna Manzi
- Department of Clinical, Anesthesiological and Cardiovascular Sciences - Sapienza University of Rome, Rome, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences - Federico II University of Naples, Naples, Italy
| | - Alexandra Mihai
- Department of Clinical, Anesthesiological and Cardiovascular Sciences - Sapienza University of Rome, Rome, Italy
| | - Massimiliano Mulè
- Cardiology Unit, IRCCS, Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione (ISMETT), Palermo, Italy
| | - Giuseppe Paciocco
- Dipartimento Cardio-Toraco-Vascolare, Clinica Pneumologica, Azienda Ospedaliera San Gerardo, Monza, Italy
| | - Silvia Papa
- Department of Clinical, Anesthesiological and Cardiovascular Sciences - Sapienza University of Rome, Rome, Italy
| | - Tommaso Recchioni
- Department of Clinical, Anesthesiological and Cardiovascular Sciences - Sapienza University of Rome, Rome, Italy
| | | | - Emanuele Romeo
- Department of Cardiology, Monaldi Hospital - University "L. Vanvitelli", Naples, Italy
| | - Davide Stolfo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Patrizio Vitulo
- Pulmonology Unit, IRCCS - Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione (ISMETT), Palermo, Italy
| | - Raymond L Benza
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Carmine D Vizza
- Department of Clinical, Anesthesiological and Cardiovascular Sciences - Sapienza University of Rome, Rome, Italy
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Hemnes AR, Celermajer DS, D'Alto M, Haddad F, Hassoun PM, Prins KW, Naeije R, Vonk Noordegraaf A. Pathophysiology of the right ventricle and its pulmonary vascular interaction. Eur Respir J 2024:2401321. [PMID: 39209482 DOI: 10.1183/13993003.01321-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 07/09/2024] [Indexed: 09/04/2024]
Abstract
The right ventricle and its stress response is perhaps the most important arbiter of survival in patients with pulmonary hypertension of many causes. The physiology of the cardiopulmonary unit and definition of right heart failure proposed in the 2018 World Symposium on Pulmonary Hypertension have proven useful constructs in subsequent years. Here, we review updated knowledge of basic mechanisms that drive right ventricular function in health and disease, and which may be useful for therapeutic intervention in the future. We further contextualise new knowledge on assessment of right ventricular function with a focus on metrics readily available to clinicians and updated understanding of the roles of the right atrium and tricuspid regurgitation. Typical right ventricular phenotypes in relevant forms of pulmonary vascular disease are reviewed and recent studies of pharmacological interventions on chronic right ventricular failure are discussed. Finally, unanswered questions and future directions are proposed.
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Affiliation(s)
- Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David S Celermajer
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michele D'Alto
- Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University and Stanford Cardiovascular Institute, Palo Alto, CA, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kurt W Prins
- Lillehei Heart Institute, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Anton Vonk Noordegraaf
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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3
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Dardi F, Boucly A, Benza R, Frantz R, Mercurio V, Olschewski H, Rådegran G, Rubin LJ, Hoeper MM. Risk stratification and treatment goals in pulmonary arterial hypertension. Eur Respir J 2024:2401323. [PMID: 39209472 DOI: 10.1183/13993003.01323-2024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 07/09/2024] [Indexed: 09/04/2024]
Abstract
Risk stratification has gained an increasing role in predicting outcomes and guiding the treatment of patients with pulmonary arterial hypertension (PAH). The most predictive prognostic factors are three noninvasive parameters (World Health Organization functional class, 6-min walk distance and natriuretic peptides) that are included in all currently validated risk stratification tools. However, suffering from limitations mainly related to reduced specificity of PAH severity, these variables may not always be adequate in isolation for guiding individualised treatment decisions. Moreover, with effective combination treatment regimens and emerging PAH therapies, markers associated with pulmonary vascular remodelling are expected to become of increasing relevance in guiding the treatment of patients with PAH. While reaching a low mortality risk, assessed with a validated risk tool, remains an important treatment goal, preliminary data suggest that invasive haemodynamics and cardiac imaging may add incremental value in guiding treatment decisions.
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Affiliation(s)
- Fabio Dardi
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Athénaïs Boucly
- Université Paris-Saclay, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Raymond Benza
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robert Frantz
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN, USA
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Horst Olschewski
- Div. Pulmonology, Department Internal Medicine, Medical University of Graz, Graz, Austria
| | - Göran Rådegran
- Department of Clinical Sciences Lund, Cardiology, Lund University and The Haemodynamic Lab, VO Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Lewis J Rubin
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Marius M Hoeper
- Department of Respiratory Medicine and Infectious Disease, Hannover Medical School and the German Center for Lung Research (DZL), Hannover, Germany
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4
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Azaredo Raposo M, Inácio Cazeiro D, Guimarães T, Lousada N, Freitas C, Brito J, Martins S, Resende C, Dorfmüller P, Luís R, Moreira S, Alves da Silva P, Moita L, Oliveira M, Pinto FJ, Plácido R. Pulmonary arterial hypertension: Navigating the pathways of progress in diagnosis, treatment, and patient care. Rev Port Cardiol 2024:S0870-2551(24)00218-X. [PMID: 38972452 DOI: 10.1016/j.repc.2024.03.004] [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: 12/27/2023] [Revised: 02/01/2024] [Accepted: 03/10/2024] [Indexed: 07/09/2024] Open
Abstract
Pulmonary arterial hypertension (PAH) is a form of precapillary pulmonary hypertension caused by a complex process of endothelial dysfunction and vascular remodeling. If left untreated, this progressive disease presents with symptoms of incapacitating fatigue causing marked loss of quality of life, eventually culminating in right ventricular failure and death. Patient management is complex and based on accurate diagnosis, risk stratification, and treatment initiation, with close monitoring of response and disease progression. Understanding the underlying pathophysiology has enabled the development of multiple drugs directed at different targets in the pathological chain. Vasodilator therapy has been the mainstay approach for the last few years, significantly improving quality of life, functional status, and survival. Recent advances in therapies targeting dysfunctional pathways beyond endothelial dysfunction may address the fundamental processes underlying the disease, raising the prospect of increasingly effective options for this high-risk group of patients with a historically poor prognosis.
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Affiliation(s)
- Miguel Azaredo Raposo
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Daniel Inácio Cazeiro
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Tatiana Guimarães
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Nuno Lousada
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Céline Freitas
- Association for Research and Development of Faculty of Medicine (AIDFM), Cardiovascular Research Support Unit (GAIC), Lisbon, Portugal
| | - Joana Brito
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Susana Martins
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Catarina Resende
- Rheumatology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Peter Dorfmüller
- Department of Pathology, University Hospital of Giessen and Marburg, Giessen, Germany; Institute for Lung Health, Giessen, Germany
| | - Rita Luís
- Pathology Department, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal; Pathology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal; Pathology Institute, Faculdade Medicina Universidade Lisboa, Lisbon, Portugal
| | - Susana Moreira
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Pedro Alves da Silva
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Luís Moita
- Innate Immunity and Inflammation Laboratory, Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | | | - Fausto J Pinto
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Rui Plácido
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal; Cardiology Department, CUF Tejo, Lisbon, Portugal.
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5
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Zhou Z, Gu Y, Tian L, Zheng H, Li S. Development and Validation of a Nomogram of Persistent Pulmonary Hypertension in Adult Pretricuspid Shunts After Correction. J Am Heart Assoc 2024; 13:e032412. [PMID: 38639332 PMCID: PMC11179888 DOI: 10.1161/jaha.123.032412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 02/05/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Pretricuspid shunts have been associated with poorer survival rates in patients with Eisenmenger syndrome compared with postricuspid shunts and complex lesions. However, the risk stratification for persistent pulmonary hypertension (PH) in this population remains uncertain. METHODS AND RESULTS We retrospectively enrolled 103 patients with pretricuspid shunts with high total pulmonary resistance >4.5 Wood units (estimated pulmonary vascular resistance ≥3 Wood units). During a mean±SD follow-up of 20.95±24.84 months, 32 patients developed postoperative persistent PH after shunt correction. We identified 3 significant predictors of postoperative persistent PH, including mean pulmonary artery pressure after inhaled oxygen ≥40.5 mm Hg (odds ratio [OR], 7.78 [95% CI, 2.02-30.03]; P<0.01), total pulmonary resistance after inhaled oxygen ≥6.5 Wood units (estimated pulmonary vascular resistance ≥5 Wood units; OR, 12.23 [95% CI, 2.12-70.46]; P<0.01), and artery oxygen saturation at rest <95% (OR, 3.34 [95% CI, 1.07-10.44]; P=0.04). We established the prediction model with the C-statistics of 0.85 (95% CI, 0.77-0.93; P<0.01), and the C-statistic was 0.83 (95% CI, 0.80-0.86) after bootstrapping 10 000 times with a good performance of the nomogram calibration curve for predicting persistent PH. CONCLUSIONS Our study presents a multivariable risk stratification model for persistent PH after shunt correction in adults with pretricuspid shunts. This model, based on 3 hemodynamic predictors after inhaled oxygen, may assist in identifying individuals at higher risk of persistent PH after shunt correction.
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Affiliation(s)
- Zeming Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
- Department of Structural Heart Disease, Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences, Peking Union Medical College Beijing China
| | - Yuanrui Gu
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - Lili Tian
- Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - Hong Zheng
- Department of Structural Heart Disease, Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences, Peking Union Medical College Beijing China
| | - Shiguo Li
- Department of Structural Heart Disease, Fuwai Hospital, National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences, Peking Union Medical College Beijing China
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6
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Waxman AB, Systrom DM, Manimaran S, de Oliveira Pena J, Lu J, Rischard FP. SPECTRA Phase 2b Study: Impact of Sotatercept on Exercise Tolerance and Right Ventricular Function in Pulmonary Arterial Hypertension. Circ Heart Fail 2024; 17:e011227. [PMID: 38572639 DOI: 10.1161/circheartfailure.123.011227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/26/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND This study aims to assess the impact of sotatercept on exercise tolerance, exercise capacity, and right ventricular function in pulmonary arterial hypertension. METHODS SPECTRA (Sotatercept Phase 2 Exploratory Clinical Trial in PAH) was a phase 2a, single-arm, open-label, multicenter exploratory study that evaluated the effects of sotatercept by invasive cardiopulmonary exercise testing in participants with pulmonary arterial hypertension and World Health Organization functional class III on combination background therapy. The primary end point was the change in peak oxygen uptake from baseline to week 24. Cardiac magnetic resonance imaging was performed to assess right ventricular function. RESULTS Among the 21 participants completing 24 weeks of treatment, there was a significant improvement from baseline in peak oxygen uptake, with a mean change of 102.74 mL/min ([95% CIs, 27.72-177.76]; P=0.0097). Sotatercept demonstrated improvements in secondary end points, including resting and peak exercise hemodynamics, and 6-minute walk distance versus baseline measures. Cardiac magnetic resonance imaging showed improvements from baseline at week 24 in right ventricular function. CONCLUSIONS The clinical efficacy and safety of sotatercept demonstrated in the SPECTRA study emphasize the potential of this therapy as a new treatment option for patients with pulmonary arterial hypertension. Improvements in right ventricular structure and function underscore the potential for sotatercept as a disease-modifying agent with reverse-remodeling capabilities. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03738150.
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Affiliation(s)
- Aaron B Waxman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.B.W., D.M.S.)
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.B.W., D.M.S.)
| | - Solaiappan Manimaran
- Acceleron Pharma, a wholly owned subsidiary of Merck & Co Inc, Rahway, NJ (S.M.)
| | | | | | - Franz P Rischard
- Department of Medicine, Division of Pulmonary and Critical Care (F.P.R.), University of Arizona, Tucson
- Sarver Heart Center (F.R.), University of Arizona, Tucson
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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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8
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Wang L, Liu J, Zhou L, Fu Q. Serum PM20D1 levels in patients with idiopathic pulmonary arterial hypertension and its clinical significance. BMC Cardiovasc Disord 2024; 24:207. [PMID: 38614995 PMCID: PMC11015596 DOI: 10.1186/s12872-024-03855-6] [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: 10/13/2023] [Accepted: 03/22/2024] [Indexed: 04/15/2024] Open
Abstract
OBJECTIVE This study aimed to investigate the serum levels of Peptidase M20 domain containing 1 (PM20D1) in idiopathic pulmonary arterial hypertension (IPAH) patients and examine its association with lipid metabolism, echocardiography, and hemodynamic parameters. METHODS This prospective observational research enrolled 103 IPAH patients from January 2018 to January 2022. Enzyme-linked immunosorbent assay (ELISA) was used to measure the serum PM20D1 levels in all patients before treatment within 24 h of admission. Demographic data, echocardiography, hemodynamic parameters and serum biomarkers were also collected. RESULTS The IPAH patients in the deceased group had significantly elevated age, right atrial (RA), mean pulmonary arterial pressure (mPAP), mean right atrial pressure (mRAP), pulmonary capillary wedge pressure (PCWP), pulmonary vascular resistance (PVR) and significantly decreased 6 min walking distance (6MWD) and tricuspid annulus peak systolic velocity (TASPV). IPAH patients showed significant decreases in serum PM20D1, low-density lipoprotein cholesterol (LDL-C), and albumin (ALB). Additionally, PM20D1 was negatively correlated with RA, NT-proBNP and positively correlated with PVR, ALB, 6MWD, and TAPSV. Moreover, PM20D1 has the potential as a biomarker for predicting IPAH patients' prognosis. Finally, logistic regression analysis indicated that PM20D1, ALB, NT-proBNP, PVR, TASPV, RA and 6MWD were identified as risk factors for mortality in IPAH patients. CONCLUSION Our findings indicated that the serum levels of PM20D1 were significantly decreased in IPAH patients with poor prognosis. Moreover, PM20D1 was identified as a risk factor associated with mortality in IPAH patients.
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Affiliation(s)
- Lin Wang
- Department of Respiratory and Critical Care Medicine, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, Zhuzhou, 412000, Hunan Province, P.R. China
| | - Jiaxiang Liu
- Department of Cardiology, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, Zhuzhou, 412000, Hunan Province, P.R. China
| | - Liufang Zhou
- Department of Anesthesiology, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, Zhuzhou, 412000, Hunan Province, P.R. China
| | - Qingmei Fu
- Department of Ultrasound, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, No.116, Changjiang South Road, Tianyuan District, Zhuzhou City, 412000, Hunan Province, P.R. China.
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9
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Fadah K, Arrington K, Khalafi S, Brockman M, Garcia H, Alkhateeb H, Mukherjee D, Nickel NP. Insights Into Differences in Pulmonary Hemodynamics in Hispanic Patients With Pulmonary Arterial Hypertension. Cardiol Res 2024; 15:117-124. [PMID: 38645831 PMCID: PMC11027778 DOI: 10.14740/cr1618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/01/2024] [Indexed: 04/23/2024] Open
Abstract
Background Emerging data suggest that Hispanic patients with pulmonary arterial hypertension (PAH) exhibit improved survival rates compared to individuals of other ethnicities with similar baseline hemodynamics. However, the underlying reasons for this survival advantage remain unclear. This study focused on comparing pulmonary hemodynamics in Hispanic and non-Hispanic PAH patients and how these differences may contribute to varied clinical outcomes. Methods A retrospective analysis of right heart catheterization data was conducted on a treatment-naive PAH patient cohort from a single center. Results Over a 10-year period, a total of 226 PAH patients were identified, of which 138 (61%) were Hispanic and 88 (39%) were non-Hispanic. Hispanic patients presented with lower pulmonary artery pressures, lower pulmonary vascular resistance, and exhibited significantly higher pulmonary arterial compliance (PAc). Hispanic patients had better 5-year survival rates. Conclusions This study highlights the importance of exploring phenotypic differences in ethnically diverse PAH cohorts.
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Affiliation(s)
- Kahtan Fadah
- Division of Cardiovascular Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, TX, USA
| | - Kedzie Arrington
- Paul Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, TX, USA
| | - Seyed Khalafi
- Paul Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, TX, USA
| | - Michael Brockman
- Department of Internal Medicine, Division of Pulmonology and Critical Care Medicine, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Hernando Garcia
- Department of Internal Medicine, Division of Pulmonology and Critical Care Medicine, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Haider Alkhateeb
- Division of Cardiovascular Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, TX, USA
| | - Nils P. Nickel
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, TX, USA
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10
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Weatherald J, Sitbon O. POINT: Should the Use of Upfront Triple Combination Therapy Be Standard of Care in Pulmonary Arterial Hypertension? Yes. Chest 2024; 165:492-494. [PMID: 38461011 DOI: 10.1016/j.chest.2023.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 03/11/2024] Open
Affiliation(s)
- Jason Weatherald
- Department of Medicine, Division of Pulmonary Medicine University of Alberta, Edmonton, AB, Canada
| | - Olivier Sitbon
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.
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11
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Rischard FP, Bernardo RJ, Vanderpool RR, Kwon DH, Acharya T, Park MM, Katrynuik A, Insel M, Kubba S, Badagliacca R, Larive AB, Naeije R, Garcia JG, Beck GJ, Erzurum SC, Frantz RP, Hassoun PM, Hemnes AR, Hill NS, Horn EM, Leopold JA, Rosenzweig EB, Wilson Tang W, Wilcox JD. Classification and Predictors of Right Ventricular Functional Recovery in Pulmonary Arterial Hypertension. Circ Heart Fail 2023; 16:e010555. [PMID: 37664964 PMCID: PMC10592283 DOI: 10.1161/circheartfailure.123.010555] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 07/17/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Normative changes in right ventricular (RV) structure and function have not been characterized in the context of treatment-associated functional recovery (RV functional recovery [RVFnRec]). The aim of this study is to assess the clinical relevance of a proposed RVFnRec definition. METHODS We evaluated 63 incident patients with pulmonary arterial hypertension by right heart catheterization and cardiac magnetic resonance imaging at diagnosis and cardiac magnetic resonance imaging and invasive cardiopulmonary exercise testing following treatment (≈11 months). Sex, age, ethnicity matched healthy control subjects (n=62) with 1-time cardiac magnetic resonance imaging and noninvasive cardiopulmonary exercise testing were recruited from the PVDOMICS (Redefining Pulmonary Hypertension through Pulmonary Vascular Disease Phenomics) project. We examined therapeutic cardiac magnetic resonance imaging changes relative to the evidence-based peak oxygen consumption (VO2peak)>15 mL/(kg·min) to define RVFnRec by receiver operating curve analysis. Afterload was measured as mean pulmonary artery pressure, resistance, compliance, and elastance. RESULTS A drop in RV end-diastolic volume of -15 mL best defined RVFnRec (area under the curve, 0.87; P=0.0001) and neared upper 95% CI RV end-diastolic volume of controls. This cutoff was met by 22 out of 63 (35%) patients which was reinforced by freedom from clinical worsening, RVFnRec 1 out of 21 (5%) versus no RVFnRec 17 out of 42, 40% (log-rank P=0.006). A therapy-associated increase of 0.8 mL/mm Hg in compliance had the best predictive value of RVFnRec (area under the curve, 0.76; [95% CI, 0.64-0.88]; P=0.001). RVFnRec patients had greater increases in stroke volume, and cardiac output at exercise. CONCLUSIONS RVFnRec defined by RV end-diastolic volume therapeutic decrease of -15 mL predicts exercise capacity, freedom from clinical worsening, and nears normalization. A therapeutic improvement of compliance is superior to other measures of afterload in predicting RVFnRec. RVFnRec is also associated with increased RV output reserve at exercise.
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Affiliation(s)
- Franz P. Rischard
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Arizona
| | - Roberto J. Bernardo
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | | | | | - Tushar Acharya
- Divison of Cardiology, University of Arizona, Tucson, AZ
| | | | | | - Michael Insel
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Arizona
| | - Saad Kubba
- Divison of Cardiology, University of Arizona, Tucson, AZ
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, Rome, Italy
| | - A Brett Larive
- Department of Quantitative Health Sciences, Cleveland Clinic
| | - Robert Naeije
- Department of Pathophysiology, Free University of Brussels, Brussels, Belgium
| | | | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic
| | | | | | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center
| | - Evelyn M Horn
- Perkin Heart Failure Center, Division of Cardiology, Weill Cornell Medicine
| | - Jane A Leopold
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - Erika B. Rosenzweig
- Department of Pediatrics and Medicine, Columbia University, Vegelos College of Physicians and Surgeons
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12
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Caputo A, Papa S, Manzi G, Laviola D, Recchioni T, Severino P, Lavalle C, Maestrini V, Mancone M, Badagliacca R, Vizza CD. Medical Management of Right Ventricular Dysfunction in Pulmonary Arterial Hypertension. Curr Heart Fail Rep 2023; 20:263-270. [PMID: 37486563 PMCID: PMC10421820 DOI: 10.1007/s11897-023-00612-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/25/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to overview the most relevant and recent knowledge regarding medical management in pulmonary arterial hypertension (PAH). RECENT FINDINGS Evidence has shown that PAH patients' quality of life and prognosis depend on the capability of the RV to adapt to increased afterload and to fully recover in response to substantially reduced pulmonary vascular resistance obtained with medical therapy. Data from recent clinical studies show that more aggressive treatment strategies, especially in higher risk categories, determine larger afterload reductions, consequentially increasing the probability of achieving right heart reverse remodeling, therefore improving the patients' survival and quality of life. Remarkable progress has been observed over the past decades in the medical treatment of PAH, related to the development of drugs that target multiple biological pathways, strategies for earlier and more aggressive treatment interventions. New hopes for treatment of patients who are unable to achieve low-risk status have been derived from the phase 2 trial PULSAR and the phase 3 trial STELLAR, which show improvement in the hemodynamic status of patients treated with sotatercept on top of background therapy. Promising results are expected from several ongoing clinical trials targeting new pathways involved in the pathophysiology of PAH.
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Affiliation(s)
- Annalisa Caputo
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Silvia Papa
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy.
| | - Giovanna Manzi
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Domenico Laviola
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Tommaso Recchioni
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Paolo Severino
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Carlo Lavalle
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Viviana Maestrini
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Massimo Mancone
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
| | - Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, viale del Policlinico 155, 00161, Rome, Italy
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13
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Yang BQ, Park AC, Liu J, Byrnes K, Javaheri A, Mann DL, Schilling JD. Distinct Inflammatory Milieu in Patients With Right Heart Failure. Circ Heart Fail 2023; 16:e010478. [PMID: 37395128 PMCID: PMC10526716 DOI: 10.1161/circheartfailure.123.010478] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/31/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Right heart failure (RHF) is associated with worse clinical outcomes. In addition to hemodynamic perturbations, the syndrome of RHF involves liver congestion and dysfunction. The mechanisms that underlie heart-liver interactions are poorly understood and may involve secreted factors. As a first step to understand the cardiohepatic axis, we sought to elucidate the circulating inflammatory milieu in patients with RHF. METHODS Blood samples were collected from the inferior vena cava and hepatic veins during right heart catheterization from 3 groups of patients: (1) controls with normal cardiac function, (2) patients with heart failure who did not meet all criteria of RHF, and (3) patients who met prespecified criteria for RHF defined by hemodynamic and echocardiographic parameters. We performed a multiplex protein assay to survey levels of several circulating markers and analyzed their association with mortality and the need for a left ventricular assist device or heart transplant. Finally, we leveraged publicly available single-cell RNA sequencing data and performed tissue imaging to evaluate the expression of these factors in the liver. RESULTS In this study, RHF was associated with elevated levels of a subset of cytokines/chemokines/growth factors compared with controls. In particular, soluble CD163 (cluster of differentiation 163) and CXCL12 (chemokine [C-X-C motif] ligand 12) were higher in RHF and predicted left ventricular assist device/transplant-free survival in an independent validation cohort. Furthermore, single-cell RNA sequencing and immunohistochemistry of human liver biopsies suggest that these factors are expressed by Kupffer cells and may be liver derived. CONCLUSIONS RHF is associated with a distinct circulating inflammatory profile. Soluble CD163 and CXCL12 are novel biomarkers that can prognosticate patient outcomes. Future studies to define how these molecules influence heart failure phenotypes and disease progression may lead to new approaches to the management of patients with RHF.
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Affiliation(s)
- Bin Q Yang
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston MA
| | - Arick C Park
- Division of Cardiology, Washington University School of Medicine in St. Louis, St. Louis MO
| | - Jason Liu
- Division of Cardiology, Texas Heart Institute, Houston TX
| | - Kathleen Byrnes
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis MO
| | - Ali Javaheri
- Division of Cardiology, Washington University School of Medicine in St. Louis, St. Louis MO
| | - Douglas L Mann
- Division of Cardiology, Washington University School of Medicine in St. Louis, St. Louis MO
| | - Joel D Schilling
- Division of Cardiology, Washington University School of Medicine in St. Louis, St. Louis MO
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis MO
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14
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Rischard FP, Bernardo RJ, Vanderpool RR, Kwon DH, Acharya T, Park MM, Katrynuik A, Insel M, Kubba S, Badagliacca R, Larive AB, Naeije R, Garcia JGN, Beck GJ, Erzurum SC, Frantz RP, Hassoun PM, Hemnes AR, Hill NS, Horn EM, Leopold JA, Rosenzweig EB, Tang WHW, Wilcox JD. Classification and Predictors of Right Ventricular Functional Recovery in Pulmonary Arterial Hypertension. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.15.23285974. [PMID: 36824981 PMCID: PMC9949192 DOI: 10.1101/2023.02.15.23285974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Background Normative changes in right ventricular (RV) structure and function have not been characterized in the context of treatment-associated functional recovery (RVFnRec). The aim of this study is to assess the clinical relevance of a proposed RVFnRec definition. Methods We evaluated 63 incident patients with PAH by right heart catheterization and cardiac MRI (CMR) at diagnosis and CMR and invasive cardiopulmonary exercise (CPET) following treatment (∼11 months). Sex, age, race/ethnicity matched healthy control subjects (n=62) with one-time CMR and non-invasive CPET were recruited from the PVDOMICS project. We examined therapeutic CMR changes relative to the evidence-based peak oxygen consumption (VO2 peak )>15mL/kg/min to define RVFnRec by receiver operating curve analysis. Afterload was measured in the as mean pulmonary artery pressure, resistance, compliance, and elastance. Results A drop in RV end-diastolic volume of -15 mL best defined RVFnRec (AUC 0.87, P=0.0001) and neared upper 95% CI RVEDV of controls. 22/63 (35%) of subjects met this cutoff which was reinforced by freedom from clinical worsening, RVFnRec 1/21 (5%) versus no RVFnRec 17/42, 40%, (log rank P=0.006). A therapy-associated increase of 0.8 mL/mmHg in compliance had the best predictive value of RVFnRec (AUC 0.76, CI 0.64-0.88, P=0.001). RVFnRec subjects had greater increases in stroke volume, and cardiac output at exercise. Conclusions RVFnRec defined by RVEDV therapeutic decrease of -15mL predicts exercise capacity, freedom from clinical worsening, and nears normalization. A therapeutic improvement of compliance is superior to other measures of afterload in predicting RVFnRec. RVFnRec is also associated with increased RV output reserve at exercise. Clinical Perspective What is new?: Right ventricular functional recovery (RVFnRec) represents a novel endpoint of therapeutic success in PAH. We define RVFnRec as treatment associated normative RV changes related to function (peak oxygen consumption). Normative RV imaging changes are compared to a well phenotyped age, sex, and race/ethnicity matched healthy control cohort from the PVDOMICS project. Previous studies have focused on RV ejection fraction improvements. However, we show that changes in RVEDV are perhaps more important in that improvements in LV function also occur. Lastly, RVFnRec is best predicted by improvements in pulmonary artery compliance versus pulmonary vascular resistance, a more often cited metric of RV afterload.What are the clinical implications?: RVFnRec represents a potential non-invasive assessment of clinical improvement and therapeutic response. Clinicians with access to cardiac MRI can obtain a limited scan (i.e., ventricular volumes) before and after treatment. Future study should examine echocardiographic correlates of RVFnRec.
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15
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Alamri AK, Shelburne NJ, Mayeux JD, Brittain E. Pulmonary Hypertension Association's 2022 International Conference Scientific Sessions Overview. Pulm Circ 2023; 13:e12182. [PMID: 36644322 PMCID: PMC9832865 DOI: 10.1002/pul2.12182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
The considerable progress made in recent years in the diagnosis, risk stratification, and treatment of pulmonary hypertension was highlighted during the most recent edition of the Pulmonary Hypertension Association Scientific Sessions, which was held in Atlanta, Georgia from June 9 to 11, 2022, with the theme: Vision for the PHuture: The Evolving Science and Management of PH. Content presented over the 3-day conference focused on scientific and management updates since the last sessions were held in 2018 and included didactic talks, debates, and roundtable discussions across a broad spectrum of topics related to pulmonary hypertension. This article aims to summarize the key messages from each of the session talks.
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Affiliation(s)
- Ayedh K. Alamri
- Department of MedicineUniversity of UtahSalt Lake CityUtahUSA,Department of Medicine, College of MedicineNorthern Border UniversityArarSaudi Arabia
| | - Nicholas J. Shelburne
- Division of Allergy, Pulmonary, and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jennalyn D. Mayeux
- Department of Medicine, Division of Pulmonary and Critical Care MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Evan Brittain
- Division of Cardiovascular MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
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16
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 501] [Impact Index Per Article: 501.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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17
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Benza RL, Langleben D, Hemnes AR, Vonk Noordegraaf A, Rosenkranz S, Thenappan T, Hassoun PM, Preston IR, Ghio S, Badagliacca R, Vizza CD, Lang IM, Meier C, Grünig E. Riociguat and the right ventricle in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2022; 31:31/166/220061. [PMID: 36198418 DOI: 10.1183/16000617.0061-2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/22/2022] [Indexed: 11/05/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are progressive diseases that can lead to right heart failure and death. Right ventricular dysfunction, hypertrophy and maladaptive remodelling are consequences of increased right ventricular (RV) afterload in PAH and CTEPH and are indicative of long-term outcomes. Because RV failure is the main cause of morbidity and mortality in PAH and CTEPH, successful treatments should lead to improvements in RV parameters. Riociguat is a soluble guanylate cyclase stimulator approved for the treatment of PAH and inoperable or persistent/recurrent CTEPH after pulmonary endarterectomy. This review examines the current evidence showing the effect of riociguat on the right ventricle, with particular focus on remodelling, function and structural parameters in preclinical models and patients with PAH or CTEPH.
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Affiliation(s)
- Raymond L Benza
- Dept of Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - David Langleben
- Center for Pulmonary Vascular Disease, Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Dept of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Stephan Rosenkranz
- Dept of Cardiology and Cologne Cardiovascular Research Center, Cologne University Heart Center, Cologne, Germany
| | - Thenappan Thenappan
- Cardiovascular Division, Dept of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Paul M Hassoun
- Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ioana R Preston
- Pulmonary, Critical Care and Sleep Medicine Division, Tufts Medical Center, Boston, MA, USA
| | - Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | | | - Irene M Lang
- Division of Cardiology, Dept of Internal Medicine II, Medical University of Vienna, Allgemeines Krankenhaus, Vienna, Austria
| | | | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik-Heidelberg gGmbH, Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
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18
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 1157] [Impact Index Per Article: 578.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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19
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Badagliacca R, Vizza CD, Lang I, Sadushi-Kolici R, Papa S, Manzi G, Filomena D, Ogawa A, Shimokawahara H, Matsubara H. Pulmonary pressure recovery in idiopathic, hereditary and drug and toxin-induced pulmonary arterial hypertension: Determinants and clinical impact. Vascul Pharmacol 2022; 146:107099. [PMID: 36058492 DOI: 10.1016/j.vph.2022.107099] [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: 06/19/2022] [Revised: 08/16/2022] [Accepted: 08/26/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Over the past two decades randomized controlled trials of combination treatments for Pulmonary Arterial Hypertension (PAH) have demonstrated improvements of clinical status but only modest reductions in mean pulmonary pressure (mPAP). Recent experiences with upfront combination treatments including parenteral prostacyclins have shown more substantial mPAP reductions, and have provided grounds for reconsiderations of treatment. OBJECTIVES To evaluate the possibility of achieving mPAP <25 mmHg with current treatments, its determinants and the prognostic impact of mPAP reduction. METHODS 267 consecutive idiopathic, hereditary and drug and toxin-induced PAH patients treated with targeted therapies from three expert centers were followed with periodic clinical and hemodynamic assessments for survival detection. RESULTS Fifty-four (20.2%) patients achieved a mPAP <25 mmHg over 58 months (IQR 27-90) of treatment. Determinants of mPAP <25 mmHg were mPAP at diagnosis (HR 0.96, 95C.I. 0.93-0.98, p = 0.002) and an upfront combination strategy (double oral combination: HR 2.3, 95C.I. 1.10-4.76, p = 0.02; one oral plus parenteral prostanoid: HR 3.6, 95C.I. 1.39-9.37, p = 0.008; triple combination employing parenteral prostanoids: HR 12.9, 95C.I. 4.9-33.2, p = 0.0001). Seventy-three patients (27.3%) died. Survival rates were 90%, 79%, 70%, 55%, and 42% at 1, 3, 5, 10, and 15 years, respectively. Mean PAP during follow-up, days from diagnosis to prostanoid initiation and prostanoid maximum dose emerged as independent predictors of survival (Uno-C-index: 0.85). A mPAP ≤35 mmHg during follow-up was identified as the best cutoff value for prediction of survival. CONCLUSIONS Reduction to a mean PAP ≤ 35 mmHg appears to be a meaningful treatment target in idiopathic, hereditary and drug and toxin-induced pulmonary arterial hypertension.
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Affiliation(s)
- Roberto Badagliacca
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy.
| | - Carmine Dario Vizza
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - Irene Lang
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | - Silvia Papa
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - Giovanna Manzi
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - Domenico Filomena
- Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - Aiko Ogawa
- Department of Clinical Science, Okayama Medical Center, Japan
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20
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Goh ZM, Balasubramanian N, Alabed S, Dwivedi K, Shahin Y, Rothman AMK, Garg P, Lawrie A, Capener D, Thompson AAR, Alandejani F, Wild JM, Johns CS, Lewis RA, Gosling R, Sharkey M, Condliffe R, Kiely DG, Swift AJ. Right ventricular remodelling in pulmonary arterial hypertension predicts treatment response. Heart 2022; 108:1392-1400. [PMID: 35512982 PMCID: PMC9380507 DOI: 10.1136/heartjnl-2021-320733] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/29/2022] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES To determine the prognostic value of patterns of right ventricular adaptation in patients with pulmonary arterial hypertension (PAH), assessed using cardiac magnetic resonance (CMR) imaging at baseline and follow-up. METHODS Patients attending the Sheffield Pulmonary Vascular Disease Unit with suspected pulmonary hypertension were recruited into the ASPIRE (Assessing the Spectrum of Pulmonary hypertension Identified at a REferral Centre) Registry. With exclusion of congenital heart disease, consecutive patients with PAH were followed up until the date of census or death. Right ventricular end-systolic volume index adjusted for age and sex and ventricular mass index were used to categorise patients into four different volume/mass groups: low-volume-low-mass, low-volume-high-mass, high-volume-low-mass and high-volume-high-mass. The prognostic value of the groups was assessed with one-way analysis of variance and Kaplan-Meier plots. Transition of the groups was studied. RESULTS A total of 505 patients with PAH were identified, 239 (47.3%) of whom have died at follow-up (median 4.85 years, IQR 4.05). The mean age of the patients was 59±16 and 161 (32.7%) were male. Low-volume-low-mass was associated with CMR and right heart catheterisation metrics predictive of improved prognosis. There were 124 patients who underwent follow-up CMR (median 1.11 years, IQR 0.78). At both baseline and follow-up, the high-volume-low-mass group had worse prognosis than the low-volume-low-mass group (p<0.001). With PAH therapy, 73.5% of low-volume-low-mass patients remained in this group, whereas only 17.4% of high-volume-low-mass patients transitioned into low-volume-low-mass. CONCLUSIONS Right ventricular adaptation assessed using CMR has prognostic value in patients with PAH. Patients with maladaptive remodelling (high-volume-low-mass) are at high risk of treatment failure.
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Affiliation(s)
- Ze Ming Goh
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Nithin Balasubramanian
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
- Radiology Department, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Krit Dwivedi
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
- INSIGNEO, Institute of Insilico Medicine, Sheffield, UK
| | - Yousef Shahin
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
- Radiology Department, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Alexander M K Rothman
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Pankaj Garg
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Allan Lawrie
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - David Capener
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - A A Roger Thompson
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Faisal Alandejani
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Jim M Wild
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
- INSIGNEO, Institute of Insilico Medicine, Sheffield, UK
| | | | - Robert A Lewis
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rebecca Gosling
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Michael Sharkey
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Robin Condliffe
- INSIGNEO, Institute of Insilico Medicine, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
- INSIGNEO, Institute of Insilico Medicine, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Andrew J Swift
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
- Radiology Department, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
- INSIGNEO, Institute of Insilico Medicine, Sheffield, UK
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21
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Manzi G, Vizza CD, Badagliacca R. Comment on Topyła-Putowska et al. Echocardiography in Pulmonary Arterial Hypertension: Comprehensive Evaluation and Technical Considerations. J. Clin. Med. 2021, 10, 3229. J Clin Med 2022; 11:jcm11123337. [PMID: 35743408 PMCID: PMC9224639 DOI: 10.3390/jcm11123337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 02/01/2023] Open
Abstract
A comprehensive PAH echocardiographic examination of patients with pulmonary arterial hypertension (PAH) should include a set of parameters resembling the pathophysiological changes occurring in the course of the disease. This approach could help clinicians build a complete picture of the patient, test the effects of targeted therapies and identify patients who need a more aggressive therapeutic approach to achieve a low risk-status.
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22
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Vizza CD, Lang IM, Badagliacca R, Benza RL, Rosenkranz S, White RJ, Adir Y, Andreassen AK, Balasubramanian V, Bartolome S, Blanco I, Bourge RC, Carlsen J, Camacho REC, D’Alto M, Farber HW, Frantz RP, Ford HJ, Ghio S, Gomberg-Maitland M, Humbert M, Naeije R, Orfanos SE, Oudiz RJ, Perrone SV, Shlobin OA, Simon MA, Sitbon O, Torres F, Luc Vachiery J, Wang KY, Yacoub MH, Liu Y, Golden G, Matsubara H. Aggressive Afterload Lowering to Improve the Right Ventricle: A New Target for Medical Therapy in Pulmonary Arterial Hypertension? Am J Respir Crit Care Med 2022; 205:751-760. [PMID: 34905704 PMCID: PMC9836222 DOI: 10.1164/rccm.202109-2079pp] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Despite numerous therapeutic advances in pulmonary arterial hypertension, patients continue to suffer high morbidity and mortality, particularly considering a median age of 50 years. This article explores whether early, robust reduction of right ventricular afterload would facilitate substantial improvement in right ventricular function and thus whether afterload reduction should be a treatment goal for pulmonary arterial hypertension. The earliest clinical studies of prostanoid treatment in pulmonary arterial hypertension demonstrated an important link between lowering mean pulmonary arterial pressure (or pulmonary vascular resistance) and improved survival. Subsequent studies of oral monotherapy or sequential combination therapy demonstrated smaller reductions in mean pulmonary arterial pressure and pulmonary vascular resistance. More recently, retrospective reports of initial aggressive prostanoid treatment or initial combination oral and parenteral therapy have shown marked afterload reduction along with significant improvements in right ventricular function. Some data suggest that reaching threshold levels for pressure or resistance (components of right ventricular afterload) may be key to interrupting the self-perpetuating injury of pulmonary vascular disease in pulmonary arterial hypertension and could translate into improved long-term clinical outcomes. Based on these clues, the authors postulate that improved clinical outcomes might be achieved by targeting significant afterload reduction with initial oral combination therapy and early parenteral prostanoids.
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Affiliation(s)
- Carmine Dario Vizza
- Dipartimento di Scienze Cliniche Internistiche Anestesiologiche e Cardiovascolari, Università di Roma La Sapienza, Rome, Italy
| | - Irene M. Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche Anestesiologiche e Cardiovascolari, Università di Roma La Sapienza, Rome, Italy
| | - Raymond L. Benza
- Division of Cardiovascular Diseases, The Ohio State University, Columbus, Ohio
| | - Stephan Rosenkranz
- Department of Cardiology, Clinic III for Internal Medicine, Cologne, Germany;,Cologne Cardiovascular Research Center, Cologne, Germany
| | - R. James White
- Department of Pulmonary and Critical Care Medicine, University of Rochester, Rochester, New York
| | - Yochai Adir
- Pulmonary Division, Carmel Medical Center, Haifa, Israel;,Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Arne K. Andreassen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Vijay Balasubramanian
- Division of Pulmonary and Critical Care, Department of Medicine, University of California San Francisco Fresno, Fresno, California
| | - Sonja Bartolome
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Isabel Blanco
- Department of Pulmonary Medicine, The August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain;,Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
| | - Robert C. Bourge
- Department of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jørn Carlsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark;,Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Rafael Enrique Conde Camacho
- Critical Medicine and Intensive Care, Pulmonology, Vascular Pulmonary Center, Pulmonology Foundation of Colombia, University Clinic Colombia, Bogota, Colombia
| | - Michele D’Alto
- Department of Cardiology, University “L. Vanvitelli,” Monaldi Hospital, Naples, Italy
| | - Harrison W. Farber
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
| | - Robert P. Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - H. James Ford
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stefano Ghio
- Division of Cardiology, San Matteo Hospital, Scientific Institute for Research, Hospitalization, and Healthcare, Pavia, Italy
| | - Mardi Gomberg-Maitland
- Department of Cardiology, School of Medicine & Health Sciences, George Washington University, Washington, D.C
| | - Marc Humbert
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtr, France;,Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique–Hôpitaux de Paris, Le Kremlin-Bicêtre, France;,Unite Mixte de Recherche S999, Hôpital Marie Lannelongue–Institut National de la Santé et de la Recherche Médicale, Le Plessis-Robinson, France
| | - Robert Naeije
- Department of Cardiology, Erasme University Hospital, Brussels, Belgium
| | - Stylianos E. Orfanos
- 1st Department of Critical Care, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ronald J. Oudiz
- Division of Cardiology, Lundquist Institute for Biomedical Research at Harbor-University of California Los Angeles Medical Center, Torrance, California
| | - Sergio V. Perrone
- Departamento Cardiologia, Instituto Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia, Buenos Aires, Argentina
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Marc A. Simon
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Olivier Sitbon
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtr, France;,Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique–Hôpitaux de Paris, Le Kremlin-Bicêtre, France;,Unite Mixte de Recherche S999, Hôpital Marie Lannelongue–Institut National de la Santé et de la Recherche Médicale, Le Plessis-Robinson, France
| | - Fernando Torres
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jean Luc Vachiery
- Pulmonary Vascular Diseases and Heart Failure Clinic, Department of Cardiology, Cliniques Universitaires de Bruxelles-Hôpital Erasme, Brussels, Belgium
| | - Kuo-Yang Wang
- Center for Pulmonary Hypertension and Pulmonary Vascular Disease, China University Hospital, Taichung, Taiwan
| | - Magdi H. Yacoub
- National Heart and Lung Institute, Heart Science Centre, Harefield Hospital, London, United Kingdom
| | - Yan Liu
- Department of Global Medical Affairs, United Therapeutics Corporation, Research Triangle Park, North Carolina; and
| | - Gil Golden
- Department of Global Medical Affairs, United Therapeutics Corporation, Research Triangle Park, North Carolina; and
| | - Hiromi Matsubara
- Department of Cardiology and Clinical Science, National Hospital Organization, Okayama Medical Center, Okayama, Japan
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23
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Computational Simulator Models and Invasive Hemodynamic Monitoring as Tools for Precision Medicine in Pulmonary Arterial Hypertension. J Clin Med 2021; 11:jcm11010082. [PMID: 35011825 PMCID: PMC8745441 DOI: 10.3390/jcm11010082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/11/2021] [Accepted: 12/21/2021] [Indexed: 12/13/2022] Open
Abstract
Precision medicine, providing the right therapeutic strategy for the right patient, could revolutionize management and prognosis of patients affected by cardiovascular diseases. Big data and artificial intelligence are pivotal for the realization of this ambitious design. In the setting of pulmonary arterial hypertension (PAH), the use of computational models and data derived from ambulatory implantable hemodynamic monitors could provide useful information for tailored treatment, as requested by precision medicine.
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24
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Gong SG, Wu WH, Li C, Zhao QH, Jiang R, Luo CJ, Qiu HL, Liu JM, Wang L, Zhang R. Validity of the ESC Risk Assessment in Idiopathic Pulmonary Arterial Hypertension in China. Front Cardiovasc Med 2021; 8:745578. [PMID: 34881304 PMCID: PMC8645595 DOI: 10.3389/fcvm.2021.745578] [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] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/25/2021] [Indexed: 01/29/2023] Open
Abstract
Background: The 2015 European pulmonary hypertension (PH) guidelines recommend a risk stratification strategy for pulmonary arterial hypertension (PAH). We aimed to investigate the validation and potential prognostic information in Chinese patients. Methods: The risk assessment variables proposed by the PH guidelines were performed by using the WHO function class, 6-min walking distance, brain natriuretic peptide or its N-terminal fragment, right arterial pressure, cardiac index, mixed venous saturation, right atrium area, pericardial effusion, peak oxygen consumption, and ventilatory equivalents for carbon dioxide. An abbreviated version also was applied. Results: A total of 392 patients with idiopathic PAH (IPAH) were enrolled between 2009 and 2018. After a median interval of 13 months, re-evaluation assessments were available for 386 subjects. The PAH guidelines risk tool may effectively discriminate three risk groups and mortality (p < 0.001) both at the baseline and re-evaluation. Meanwhile, its simplified risk version was valid for baseline and accurately predicted the risk of death in all the risk groups (p < 0.001). At the time of re-evaluation, the percentage of low-risk group has an increase, but a greater proportion achieved the high-risk group and a lesser proportion maintained in the intermediate-risk group. Conclusion: The 2015 European PH guidelines and its simplified version risk stratification assessment present an effective discrimination of different risk groups and accurate mortality estimates in Chinese patients with IPAH. Changes of risk proportion at re-evaluation implicated that natural treatment decisions may not be consistently with goal-oriented treatment strategy.
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Affiliation(s)
- Su-Gang Gong
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wen-Hui Wu
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chao Li
- Tongji University School of Medicine, Shanghai, China
| | - Qin-Hua Zhao
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rong Jiang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ci-Jun Luo
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hong-Ling Qiu
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jin-Ming Liu
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lan Wang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rui Zhang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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25
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Naeije R, Richter MJ, Rubin LJ. The physiologic basis of pulmonary arterial hypertension. Eur Respir J 2021; 59:13993003.02334-2021. [PMID: 34737219 PMCID: PMC9203839 DOI: 10.1183/13993003.02334-2021] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/18/2021] [Indexed: 11/05/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare dyspnea-fatigue syndrome caused by a progressive increase in pulmonary vascular resistance (PVR) and eventual right ventricular (RV) failure. In spite of extensive pulmonary vascular remodeling, lung function in PAH is generally well preserved, with hyperventilation and increased physiologic dead space, but minimal changes in lung mechanics and only mild to moderate hypoxemia and hypocapnia. Hypoxemia is mainly caused by a low mixed venous PO2 from a decreased cardiac output. Hypocapnia is mainly caused by an increased chemosensitivity. Exercise limitation in PAH is cardiovascular rather than ventilatory or muscular. The extent of pulmonary vascular disease in PAH is defined by multipoint pulmonary vascular pressure-flow relationships with a correction for hematocrit. Pulsatile pulmonary vascular pressure-flow relationships in PAH allow for the assessment of RV hydraulic load. This analysis is possible either in the frequency-domain or in the time-domain. The RV in PAH adapts to increased afterload by an increased contractility to preserve its coupling to the pulmonary circulation. When this homeometric mechanism is exhausted, the RV dilates to preserve flow output by an additional heterometric mechanism. Right heart failure is then diagnosed by imaging of increased right heart dimensions and clinical systemic congestion signs and symptoms. The coupling of the RV to the pulmonary circulation is assessed by the ratio of end-systolic to arterial elastances, but these measurements are difficult. Simplified estimates of RV-PA coupling can be obtained by magnetic resonance or echocardiographic imaging of ejection fraction.
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Affiliation(s)
| | - Manuel J Richter
- Department of Internal Medicine, Justus Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Lewis J Rubin
- University of California, San Diego, La Jolla, CA, USA
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26
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Deng J. Clinical application of pulmonary vascular resistance in patients with pulmonary arterial hypertension. J Cardiothorac Surg 2021; 16:311. [PMID: 34670595 PMCID: PMC8527803 DOI: 10.1186/s13019-021-01696-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/11/2021] [Indexed: 12/03/2022] Open
Abstract
Pulmonary arterial hypertension is a type of malignant pulmonary vascular disease, which is mainly caused by the increase of pulmonary vascular resistance due to the pathological changes of the pulmonary arteriole itself, which eventually leads to right heart failure and death. As one of the diagnostic indicators of hemodynamics, pulmonary vascular resistance plays an irreplaceable role in the pathophysiology, diagnosis and treatment of pulmonary arterial hypertension. It provides more references for the evaluation of pulmonary arterial hypertension patients. This article summarizes the clinical application of pulmonary vascular resistance in patients with pulmonary arterial hypertension.
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Affiliation(s)
- Jianying Deng
- Department of Cardiovascular Surgery, Chongqing Kanghua Zhonglian Cardiovascular Hospital, 168# Haier Road, District of Jiangbei, Chongqing, 400015, China.
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27
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Vanderpool RR, Hunter KS, Insel M, Garcia JGN, Bedrick EJ, Tedford RJ, Rischard FP. The Right Ventricular-Pulmonary Arterial Coupling and Diastolic Function Response to Therapy in Pulmonary Arterial Hypertension. Chest 2021; 161:1048-1059. [PMID: 34637777 DOI: 10.1016/j.chest.2021.09.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/14/2021] [Accepted: 09/25/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Multiparametric risk assessment is used in pulmonary arterial hypertension (PAH) to target therapy. However, this strategy is imperfect as most patients remain in intermediate or high risk after initial treatment with low risk being the goal. Metrics of right ventricular (RV) adaptation are promising tools that may help refine our therapeutic strategy. RESEARCH QUESTION Does RV adaptation predict therapeutic response over time? STUDY DESIGN AND METHODS We evaluated 52 incident treatment naïve patients with advanced PAH by catheterization and cardiac imaging longitudinally at baseline, follow-up 1 (∼3 mo.) and follow-up 2 (∼18 mo.). All patients were placed on goal-directed therapy with parenteral treprostinil and/or combination therapy with treatment escalation if functional class I-II was not achieved. Therapeutic response was evaluated at follow-up 1 as non-responders (died) or responders and again at follow-up 2 as super-responders (low risk) or partial-responders (high/intermediate risk). Multiparametric risk was based on a simplified ERS/ESC guideline score. RV adaptation was evaluated with the single-beat coupling ratio (Ees/Ea) and diastolic function with diastolic elastance (Eed). Data are expressed as mean±SD or odds ratio [95%CI]. RESULTS Nine patients (17%) were non-responders. PAH-directed therapy improved ERS low risk from 1 (2%) at baseline to 23 (55%) at follow-up 2. Ees/Ea at presentation was non-significantly higher in responders (0.9±0.4) versus non-responders (0.6±0.4, p=0.09) but was unable to predict super-responder status at follow-up 2 (odds ratio 1.40 [0.28-7.0], p=0.84). Baseline RVEF and change in Eed successfully predicted super-responder status at follow-up 2 (odds ratio 1.15 [1.0-1.27], p=0.009 and 0.29 [0.86-0.96], p=0.04, respectively). INTERPRETATION In patients with advanced PAH, RV-PA coupling could not discriminate irreversible RV failure (non-responders) at presentation but showed a late trend to improvement by follow-up 2. Early change in Eed and baseline RVEF were the best predictors of therapeutic response.
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Affiliation(s)
| | - Kendall S Hunter
- Department of Bioengineering and Cardiology, UC Denver Medical Campus, Denver, CO
| | - Michael Insel
- Division of Pulmonary, Critical Care, Sleep, and Allergy Medicine, University of Arizona, Tucson, AZ
| | - Joe G N Garcia
- Department of Medicine, University of Arizona, Tucson, AZ; Division of Pulmonary, Critical Care, Sleep, and Allergy Medicine, University of Arizona, Tucson, AZ
| | - Edward J Bedrick
- BIO5 Institute, Center of Biostatistics and Informatics, University of Arizona, Tucson, AZ
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Franz P Rischard
- Department of Medicine, University of Arizona, Tucson, AZ; Division of Pulmonary, Critical Care, Sleep, and Allergy Medicine, University of Arizona, Tucson, AZ.
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28
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Zhao QH, Gong SG, Jiang R, Li C, Chen GF, Luo CJ, Qiu HL, Liu JM, Wang L, Zhang R. Echocardiographic Prognosis Relevance of Attenuated Right Heart Remodeling in Idiopathic Pulmonary Arterial Hypertension. Front Cardiovasc Med 2021; 8:650848. [PMID: 34026869 PMCID: PMC8137976 DOI: 10.3389/fcvm.2021.650848] [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] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Right ventricular (RV) function is a great determination of the fate in patients with pulmonary arterial hypertension (PAH). Monitoring RV structure back to normal or improvement should be useful for evaluation of RV function. The aims of this study were to assess the prognostic relevance of changed right heart (RH) dimensions by echocardiography and attenuated RH remodeling (ARHR) in idiopathic PAH (IPAH). Methods: We retrospectively analyzed 232 consecutive adult IPAH patients at baseline assessment and included RH catheterization and echocardiography. ARHR at the mean 20 ± 12 months' follow-up was defined by a decreased right atrium area, RV mid-diameter, and left ventricular end-diastolic eccentricity index. The follow-up end point was all-cause mortality. Results: At mean 20 ± 12 months' follow-up, 33 of 232 patients (14.2%) presented with ARHR. The remaining 199 surviving patients were monitored for another 25 ± 20 months. At the end of follow-up, the survival rates at 1, 3, and 5 years were 89, 89, and 68% in patients with ARHR, respectively, and 84, 65 and 41% in patients without ARHR (log-rank p = 0.01). ARHR was an independent prognostic factor for mortality. Besides, ARHR was available to further stratify patients' risk assessment through the French PAH non-invasive-risk criteria. Conclusions: Echocardiographic ARHR is an independent determinant of prognosis in IPAH at long-term follow-up. ARHR might be a useful tool to indicate the RV morphologic and functional improvement associated with better prognostic likelihood.
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Affiliation(s)
- Qin-Hua Zhao
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Su-Gang Gong
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rong Jiang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chao Li
- Tongji University School of Medicine, Shanghai, China
| | - Ge-Fei Chen
- Department of Biosciences and Nutrition, Karolinska Institutet, Stockholm, Sweden
| | - Ci-Jun Luo
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hong-Ling Qiu
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jin-Ming Liu
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lan Wang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Tongji University School of Medicine, Shanghai, China
| | - Rui Zhang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Tongji University School of Medicine, Shanghai, China
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Dignam JP, Scott TE, Kemp-Harper BK, Hobbs AJ. Animal models of pulmonary hypertension: Getting to the heart of the problem. Br J Pharmacol 2021; 179:811-837. [PMID: 33724447 DOI: 10.1111/bph.15444] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/04/2021] [Accepted: 03/06/2021] [Indexed: 12/12/2022] Open
Abstract
Despite recent therapeutic advances, pulmonary hypertension (PH) remains a fatal disease due to the development of right ventricular (RV) failure. At present, no treatments targeted at the right ventricle are available, and RV function is not widely considered in the preclinical assessment of new therapeutics. Several small animal models are used in the study of PH, including the classic models of exposure to either hypoxia or monocrotaline, newer combinational and genetic models, and pulmonary artery banding, a surgical model of pure RV pressure overload. These models reproduce selected features of the structural remodelling and functional decline seen in patients and have provided valuable insight into the pathophysiology of RV failure. However, significant reversal of remodelling and improvement in RV function remains a therapeutic obstacle. Emerging animal models will provide a deeper understanding of the mechanisms governing the transition from adaptive remodelling to a failing right ventricle, aiding the hunt for druggable molecular targets.
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Affiliation(s)
- Joshua P Dignam
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Tara E Scott
- Department of Pharmacology, Cardiovascular Disease Program, Biomedicine Discovery Institute, Monash University Clayton Campus, Clayton, Victoria, Australia.,Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University Parkville Campus, Parkville, Victoria, Australia
| | - Barbara K Kemp-Harper
- Department of Pharmacology, Cardiovascular Disease Program, Biomedicine Discovery Institute, Monash University Clayton Campus, Clayton, Victoria, Australia
| | - Adrian J Hobbs
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Escribano Subías P, Aurtenetxe Pérez A, Pérez Olivares C, Gómez Climent L, Diago Cabezudo JI, Perelló MF. Recent advances in the management of pulmonary arterial hypertension: lessons from the upfront combination of ambrisentan and tadalafil. Expert Rev Respir Med 2021; 15:493-504. [PMID: 33472458 DOI: 10.1080/17476348.2021.1878027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The sixth World Symposium of Pulmonary Hypertension (sixth WSPH) brought to the forefront for the first time the value of earlier, aggressive management with an upfront oral combination in patients with pulmonary arterial hypertension (PAH) of low or intermediate risk. This was prompted by results from the AMBITION study (ambrisentan + tadalafil). A literature search was conducted to collect all evidence provided by upfront treatment with this combination, as well as other combinations under investigation at the time the manuscript was prepared. AREAS COVERED The value of an upfront oral combination with ambrisentan and tadalafil is reviewed on the basis of topics discussed at the sixth WSPH, such as evidence in different PAH etiologies, according to risk stratification and in so-called 'atypical' patients where monotherapy is still recommended. Evidence in clinical practice is also reviewed. New evidence about the value of the upfront oral combination is also commented. Finally, tendencies in primary endpoints to assess the effect of PAH-targeted therapies (time to clinical worsening and hemodynamics) and their value are also reviewed. EXPERT OPINION All above-mentioned aspects are put into perspective with regard to the impact of new advances on improving PAH management in clinical practice.
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Affiliation(s)
- Pilar Escribano Subías
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Unidad Multidisciplinar de Hipertensión Pulmonar, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Agueda Aurtenetxe Pérez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Servicio de Neumología, Hospital Universitario Basurto, Bilbao, Spain
| | - Carmen Pérez Olivares
- Unidad Multidisciplinar de Hipertensión Pulmonar, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain.,Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
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Miotti C, Papa S, Manzi G, Scoccia G, Luongo F, Toto F, Malerba C, Cedrone N, Sciomer S, Ciciarello F, Fedele F, Vizza CD, Badagliacca R. The Growing Role of Echocardiography in Pulmonary Arterial Hypertension Risk Stratification: The Missing Piece. J Clin Med 2021; 10:619. [PMID: 33561999 PMCID: PMC7915820 DOI: 10.3390/jcm10040619] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/29/2021] [Accepted: 02/02/2021] [Indexed: 12/17/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare, progressive disease with a poor prognosis. The pathophysiologic model is mainly characterized by an afterload mismatch in which an increased right ventricle afterload, driven by increased pulmonary vascular resistance (PVR), leads to right heart failure. International guidelines recommend optimization of treatment based on regular risk assessments to achieve or maintain a low-risk status. Current risk scores are based on a multi-modality approach, including demographic, clinical, functional, exercise, laboratory, and hemodynamic parameters, which lack significant echocardiographic parameters. The originality of echocardiography relies on the opportunity to assess in a non-invasive way a physiologically meaningful combination of easy to measure variables tightly related to right ventricle adaptation/maladaptation to increased afterload, the main determinant of a patient's prognosis. Echo-derived morphological and functional parameters have been investigated in PAH, proving to have prognostic relevance. Different therapeutic strategies proved to have different effects in reducing PVR. An upfront combination of drugs, including a parenteral prostacyclin, has shown to be associated with right heart reverse remodeling in a greater proportion of patients than other treatment strategies as a function of PVR reduction. Adding echocardiographic data to current risk scores would allow better identification of right ventricle (RV) adaptation in PAH patients' follow-up. This additional information would allow better stratification of the patient, leading to optimized and personalized therapeutic management.
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Affiliation(s)
- Cristiano Miotti
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Silvia Papa
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Giovanna Manzi
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Gianmarco Scoccia
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Federico Luongo
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Federica Toto
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Claudia Malerba
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Nadia Cedrone
- Internal Medicine Department, Ospedale S. Pertini, 00157 Rome, Italy;
| | - Susanna Sciomer
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Francesco Ciciarello
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Francesco Fedele
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Sciences—Sapienza University of Rome, 00161 Rome, Italy; (C.M.); (S.P.); (G.M.); (G.S.); (F.L.); (F.T.); (C.M.); (S.S.); (F.C.); (F.F.); (C.D.V.)
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van der Bruggen CE, Handoko ML, Bogaard HJ, Marcus JT, Oosterveer FPT, Meijboom LJ, Westerhof BE, Vonk Noordegraaf A, de Man FS. The Value of Hemodynamic Measurements or Cardiac MRI in the Follow-up of Patients With Idiopathic Pulmonary Arterial Hypertension. Chest 2020; 159:1575-1585. [PMID: 33197401 PMCID: PMC8039009 DOI: 10.1016/j.chest.2020.10.077] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 10/04/2020] [Accepted: 10/21/2020] [Indexed: 11/30/2022] Open
Abstract
Background Treatment of patients with pulmonary arterial hypertension (PAH) is conventionally based on functional plus invasive measurements obtained during right heart catheterization (RHC). Whether risk assessment during repeated measurements could also be performed on the basis of imaging parameters is unclear, as a direct comparison of strategies is lacking. Research Question How does the predictive value of noninvasive parameters compare with that of invasive hemodynamic measurements 1 year after the diagnosis of idiopathic PAH? Study Design and Methods One hundred and eighteen patients with idiopathic PAH who underwent RHC and cardiac MRI (CMR) were included in this study (median time between baseline evaluation and first parameter measures, 1.0 [0.8-1.2] years). Forty-four patients died or underwent lung transplantation. Forward Cox regression analyses were done to determine the best predictive functional, hemodynamic, and/or imaging model. Patients were classified as high risk if the event occurred < 5 years after diagnosis (n = 24), whereas patients without event were classified as low risk. Results A prognostic model based on age, sex, and absolute values at follow-up of functional parameters (6-min walk distance) performed well (Akaike information criterion [AIC], 279; concordance, 0.67). Predictive models with only hemodynamic (right atrial pressure, mixed venous oxygen saturation; AIC, 322; concordance, 0.66) or imaging parameters (right ventricular ejection fraction; AIC, 331; concordance, 0.63) at 1 year of follow-up performed similarly. The predictive value improved when functional data were combined with either hemodynamic data (AIC, 268; concordance, 0.69) or imaging data (AIC, 273; concordance, 0.70). A model composed of functional, hemodynamic, and imaging data performed only marginally better (AIC, 266; concordance, 0.69). Finally, changes between baseline and 1-year follow-up were observed for multiple hemodynamic and CMR parameters; only a change in CMR parameters was of prognostic predictive value. Interpretation At 1 year of follow-up, risk assessment based on CMR is at least equal to risk assessment based on RHC. In this study, only changes in CMR, but not hemodynamic parameters, were of prognostic predictive value during the first year of follow-up.
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Affiliation(s)
- Cathelijne Emma van der Bruggen
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Martin Louis Handoko
- Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Harm Jan Bogaard
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Johannes Timotheus Marcus
- Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Lilian Jacoba Meijboom
- Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Berend Eric Westerhof
- Cardiovascular and Respiratory Physiology, Faculty of Science and Technology, Technical Medical Center, University of Twente, Enschede, The Netherlands
| | - Anton Vonk Noordegraaf
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Frances S de Man
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
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Balloon Pulmonary Angioplasty in Patients with Chronic Thromboembolic Pulmonary Hypertension: Impact on Clinical and Hemodynamic Parameters, Quality of Life and Risk Profile. J Clin Med 2020; 9:jcm9113608. [PMID: 33182415 PMCID: PMC7697583 DOI: 10.3390/jcm9113608] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 12/01/2022] Open
Abstract
Balloon pulmonary angioplasty (BPA) is a novel treatment option for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are not eligible for pulmonary endarterectomy (PEA) or suffer from persistent pulmonary hypertension after PEA. The aim of this study was to evaluate the real-life efficacy and safety of BPA in a consecutive group of patients who were diagnosed and treated in the national referral center for CTEPH in the Czech Republic. Here we report data from 160 BPA procedures performed in 64 patients. Efficacy analysis was performed in the subgroup of 25 patients who completed BPA series. Significant improvements were observed in New York Heart Association functional class (4% to 79% in I/II, p < 0.001), 6 min walking test distance (+54.3 m, p < 0.001), risk profile (15.8% to 68.5% with presence of 2/3 low risk criteria, p < 0.001), pulmonary artery mean pressure (−18%, p < 0.001), pulmonary vascular resistance (−32%, p < 0.001), stroke volume (+17%, p = 0.011) and quality of life (+37% in assessment of overall health status by a patient, p < 0.001). We observed 1 fatal periprocedural complication (1.6% of all 64 patients) and 19 BPA-related non-fatal complications (11.9% of all 160 interventions) that predominantly included hemoptysis (10.0% of all sessions). Overall survival at 12 months was 94.6%.
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Multidimensional assessment and cluster analysis for idiopathic pulmonary arterial hypertension phenotyping. J Heart Lung Transplant 2020; 40:166-167. [PMID: 33243664 DOI: 10.1016/j.healun.2020.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 11/02/2020] [Indexed: 01/26/2023] Open
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Lachant DJ, Light A, Offen M, Adams J, White RJ. Heart rate monitoring improves clinical assessment during 6-min walk. Pulm Circ 2020; 10:2045894020972572. [PMID: 33354315 PMCID: PMC7734514 DOI: 10.1177/2045894020972572] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 10/20/2020] [Indexed: 11/17/2022] Open
Abstract
Right ventricular (RV) function is a predictor of outcomes in pulmonary arterial hypertension (PAH). The 6-min walk test (6MWT) is likely an indirect measure of RV function during exercise, but changes in absolute walk distance can also be influenced by factors like effort and musculoskeletal disease. Paired 6MWT with continuous electrocardiogram monitoring was performed in stable PAH patients, patients adding PAH therapies, and healthy controls. Heart rate expenditure (HRE) was calculated (integrating pulse during 6MWT) and then divided by walk distance (HRE/d). We also evaluated changes in peak heart rate, time above age-adjusted maximum predicted heart rate, and heart rate at 6 min. HRE/d was compared to invasive hemodynamic measures in patients who had right heart catheterization performed within seven days, WHO functional class assessment, and Emphasis 10 questionnaire. We measured two 6MWT in 15 stable PAH patients, 13 treatment intensification patients, and 8 healthy controls. HRE/d was reproducible in the stable PAH group (median difference, -0.79%), while it decreased (median difference, 23%, p = 0.0001) after adding vasodilator therapy. In 11 patients with right heart catheterization, HRE/d correlated strongly with stroke volume, r = -0.72, p = 0.01. Peak heart rate decreased after adding vasodilator therapy. HRE/d also correlated with WHO functional class and Emphasis 10 score. Continuous heart rate monitoring during 6MWT provides valuable physiologic data accounting for effort. HRE/d appears to enhance test reproducibility in stable patients while detecting change after adding therapy as compared to walk distance alone.
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Affiliation(s)
- Daniel J. Lachant
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Allison Light
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Melissa Offen
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Jamie Adams
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - R. James White
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY, USA
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Benza RL, Corris PA, Klinger JR, Langleben D, Naeije R, Simonneau G, Ghofrani HA, Jansa P, Rosenkranz S, Scelsi L, Thenappan T, Raina A, Meier C, Busse D, Hoeper MM. Identifying potential parameters associated with response to switching from a PDE5i to riociguat in RESPITE. Int J Cardiol 2020; 317:188-192. [DOI: 10.1016/j.ijcard.2020.05.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 04/14/2020] [Accepted: 05/14/2020] [Indexed: 12/14/2022]
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Badagliacca R, Vizza CD. Imaging risk in pulmonary arterial hypertension. Eur Respir J 2020; 56:56/3/2002313. [DOI: 10.1183/13993003.02313-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 06/23/2020] [Indexed: 12/15/2022]
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D'Alto M, Badagliacca R, Lo Giudice F, Argiento P, Casu G, Corda M, Correale M, Ghio S, Greco A, Lattanzio M, Mercurio V, Paciocco G, Papa S, Prediletto R, Romeo E, Russo MG, Tayar A, Vitulo P, Vizza CD, Golino P, Naeije R. Hemodynamics and risk assessment 2 years after the initiation of upfront ambrisentan‒tadalafil in pulmonary arterial hypertension. J Heart Lung Transplant 2020; 39:1389-1397. [PMID: 32933828 DOI: 10.1016/j.healun.2020.08.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/26/2020] [Accepted: 08/26/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Upfront combination therapy with ambrisentan and tadalafil has been reported to improve the condition of patients with pulmonary arterial hypertension (PAH) more than with either drug alone. However, little is known about the long-term associated changes in hemodynamics and risk assessment scores. METHODS This was a multicenter, retrospective analysis of clinical data in 106 patients with newly diagnosed PAH. Clinical evaluations, including demographics, medical history, World Health Organization (WHO) functional class (FC) and 6-minute walk distance (6MWD), right heart catheterization, and Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL) risk score 2.0, were assessed over 48 months of ambrisentan‒tadalafil therapy. RESULTS At baseline, 9 patients (9%) showed a low (<7), 48 patients (45%) showed an intermediate (7-8), and 49 patients (46%) showed a high (>8) REVEAL risk score. At a median follow-up of 2 years, 45 patients (43%) showed a low, 47 patients (44%) showed an intermediate, and 14 patients (13%) showed a high REVEAL score, along with improvements in WHO FC, 6MWD and a decrease in mean pulmonary artery pressure and N-terminal pro brain natriuretic peptide (all p < 0.001). Pulmonary vascular resistance (PVR) decreased by 37% from 11.5 ± 6.5 to 7.2 ± 4.1 Wood units (p < 0.001). A total of 61 patients (57%) remained in intermediate-risk or high-risk categories. Low-risk patients had either a decrease in PVR of >50% or a stroke volume within the limits of normal. CONCLUSIONS Initial combination therapy with ambrisentan and tadalafil in PAH improves the REVEAL risk score in proportion to decreased PVR and preserved stroke volume but still insufficiently so in approximately 50% of the patients.
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Affiliation(s)
- Michele D'Alto
- Department of Cardiology, Monaldi Hospital, "L. Vanvitelli" University, Naples, Italy; Italian Pulmonary Hypertension Network (iPHnet), Italy.
| | - Roberto Badagliacca
- Italian Pulmonary Hypertension Network (iPHnet), Italy; Department of Cardiology, La Sapienza University, Rome, Italy
| | - Francesco Lo Giudice
- Italian Pulmonary Hypertension Network (iPHnet), Italy; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Paola Argiento
- Department of Cardiology, Monaldi Hospital, "L. Vanvitelli" University, Naples, Italy; Italian Pulmonary Hypertension Network (iPHnet), Italy
| | - Gavino Casu
- Italian Pulmonary Hypertension Network (iPHnet), Italy; Department of Cardiology, Ospedale San Francesco, Nuoro, Italy
| | - Marco Corda
- Italian Pulmonary Hypertension Network (iPHnet), Italy; Department of Cardiology, Ospedale Brotzu, Cagliari, Italy
| | - Michele Correale
- Italian Pulmonary Hypertension Network (iPHnet), Italy; Department of Cardiology, Ospedali Riuniti University Hospital, Foggia, Italy
| | - Stefano Ghio
- Italian Pulmonary Hypertension Network (iPHnet), Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandra Greco
- Italian Pulmonary Hypertension Network (iPHnet), Italy; Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mariangela Lattanzio
- Italian Pulmonary Hypertension Network (iPHnet), Italy; Department of Cardiovascular Disease, Fondazione Macchi ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Valentina Mercurio
- Italian Pulmonary Hypertension Network (iPHnet), Italy; Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Giuseppe Paciocco
- Italian Pulmonary Hypertension Network (iPHnet), Italy; Department of Pulmonology, University of Milano-Bicocca, Monza, Italy
| | - Silvia Papa
- Italian Pulmonary Hypertension Network (iPHnet), Italy; Department of Cardiology, La Sapienza University, Rome, Italy
| | - Renato Prediletto
- Italian Pulmonary Hypertension Network (iPHnet), Italy; Department of Pulmonology, CNR Tuscany Region Gabriele Monasterio Foundation and Institute of Clinical Physiology, Pisa, Italy
| | - Emanuele Romeo
- Department of Cardiology, Monaldi Hospital, "L. Vanvitelli" University, Naples, Italy; Italian Pulmonary Hypertension Network (iPHnet), Italy
| | - Maria Giovanna Russo
- Department of Cardiology, Monaldi Hospital, "L. Vanvitelli" University, Naples, Italy
| | - Alessandro Tayar
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Patrizio Vitulo
- Italian Pulmonary Hypertension Network (iPHnet), Italy; Cardiothoracic and transplant Department, IRCCS Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (ISMETT), Palermo, Italy
| | - Carmine Dario Vizza
- Italian Pulmonary Hypertension Network (iPHnet), Italy; Department of Cardiology, La Sapienza University, Rome, Italy
| | - Paolo Golino
- Department of Cardiology, Monaldi Hospital, "L. Vanvitelli" University, Naples, Italy
| | - Robert Naeije
- Department of Pathophysiology, Free University of Brussels, Brussels, Belgium
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Naeije R, Richter MJ, Vanderpool R, Tello K. When it all comes down to pressure: right ventricular ejection fraction at cardiac catheterisation. Eur Respir J 2020; 55:55/3/1902341. [DOI: 10.1183/13993003.02341-2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 12/10/2019] [Indexed: 01/29/2023]
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Jone PN, Schäfer M, Pan Z, Ivy DD. Right Ventricular-Arterial Coupling Ratio Derived From 3-Dimensional Echocardiography Predicts Outcomes in Pediatric Pulmonary Hypertension. Circ Cardiovasc Imaging 2019; 12:e008176. [PMID: 30632388 DOI: 10.1161/circimaging.118.008176] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Right ventricular (RV) function is an important determinant of outcomes in pulmonary hypertension (PH). RV-arterial coupling ratio using stroke volume (SV) to end-systolic volume (ESV) has been shown to be an independent predictor of outcome in adults with PH. SV/ESV has not been used in pediatrics to predict outcomes. We compared SV/ESV between pediatric patients with PH, controls, and among groups based on disease severity. We correlated SV/ESV to RV strain and evaluated SV/ESV as a predictor of outcomes in pediatric PH. METHODS One hundred and twenty-five children with PH (8 years [3-12 years]) underwent 3-dimensional echocardiography from 2014 to 2017 and compared with 65 controls (9 years [7-13 years]). Offline analysis generated 3-dimensional end-diastolic volume, ESV, SV, and free-wall RV longitudinal strain. SV/ESV ratios were compared between patients with PH, controls, and disease severity. Correlations between SV/ESV to free-wall RV longitudinal strain were assessed using general linear mixed models. Cox proportional hazards analysis assessed the predictive ability of SV/ESV. RESULTS Patients with PH had lower SV/ESV compared with controls (0.88±0.18 versus 1.24±0.23; P<0.0001). There were significant associations between SV/ESV to free-wall RV longitudinal strain (r=-0.53; P<0.001). SV/ESV emerged as a strong predictor of adverse clinical event (hazard ratio [CI], 0.52 [0.38-0.69] per 0.1 increase in SV/ESV; P<0.0001). CONCLUSIONS SV/ESV as a volume estimate of RV-arterial coupling ratio correlates with RV strain and is a strong predictor of adverse clinical events in pediatric PH.
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Affiliation(s)
- Pei-Ni Jone
- Department of Pediatrics, Pediatric Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (P.-N.J., M.S., D.D.I.)
| | - Michal Schäfer
- Department of Pediatrics, Pediatric Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (P.-N.J., M.S., D.D.I.)
| | - Zhaoxing Pan
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Denver (Z.P.)
| | - D Dunbar Ivy
- Department of Pediatrics, Pediatric Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (P.-N.J., M.S., D.D.I.)
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D'Alto M, Badagliacca R, Argiento P, Romeo E, Farro A, Papa S, Sarubbi B, Russo MG, Vizza CD, Golino P, Naeije R. Risk Reduction and Right Heart Reverse Remodeling by Upfront Triple Combination Therapy in Pulmonary Arterial Hypertension. Chest 2019; 157:376-383. [PMID: 31563498 DOI: 10.1016/j.chest.2019.09.009] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/27/2019] [Accepted: 09/08/2019] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Combinations of therapies are currently recommended for patients with severe pulmonary arterial hypertension (PAH), and excellent results have been reported with triple upfront combination of these drugs. We evaluated the effects of this approach on right ventricular (RV) function and outcome in patients with severe PAH. METHODS Twenty-one patients (age, 44 ± 15 years) with newly diagnosed high-risk idiopathic PAH that was nonreversible by the inhalation of nitric oxide were treated upfront with a combination of ambrisentan, tadalafil, and subcutaneous treprostinil between 2014 and 2018. Clinical evaluation, World Health Organization functional class, 6-min walk distance, biomarkers, echocardiography, and right-sided heart catheterization data were recorded at baseline and during follow-up. RESULTS At a median follow-up of 2 years, all patients were still alive. The Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management score decreased from 10 ± 1 to 5 ± 1, right-sided atrial pressure decreased from 13 ± 3 to 5 ± 2 mm Hg, mean pulmonary artery pressure decreased from 60 ± 9 to 42 ± 5 mm Hg, pulmonary vascular resistance (PVR) decreased from 16.4 ± 4.4 to 5.5 ± 1.3 Wood units, N-terminal pro-brain natriuretic peptide decreased from 3,379 ± 1,921 to 498 ± 223 pg/mL, and World Health Organization functional class decreased from 3.4 ± 0.5 to 2.0 ± 0.4 (all P < .001). Cardiac index increased from 1.8 ± 0.3 to 3.5 ± 0.8 L/min/m2 and 6-min walk distance increased from 158 ± 130 to 431 ± 66 m (both P < .001). Echocardiography showed decreased right-sided atrial and RV areas, improved left ventricular eccentricity index, and increased fractional area change (all P < .001) in proportion to treatment-induced decrease in PVR. CONCLUSIONS Triple upfront combination therapy with ambrisentan, tadalafil, and subcutaneous treprostinil in severe nonreversible PAH is associated with considerable clinical and hemodynamic improvement and right-sided heart reverse remodeling.
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Affiliation(s)
- Michele D'Alto
- Department of Cardiology, Monaldi Hospital - "L. Vanvitelli" University, Naples, Italy.
| | | | - Paola Argiento
- Department of Cardiology, Monaldi Hospital - "L. Vanvitelli" University, Naples, Italy
| | - Emanuele Romeo
- Department of Cardiology, Monaldi Hospital - "L. Vanvitelli" University, Naples, Italy
| | - Andrea Farro
- Department of Cardiology, Monaldi Hospital - "L. Vanvitelli" University, Naples, Italy
| | - Silvia Papa
- Department of Cardiology, La Sapienza University, Rome, Italy
| | - Berardo Sarubbi
- Department of Cardiology, Monaldi Hospital - "L. Vanvitelli" University, Naples, Italy
| | - Maria Giovanna Russo
- Department of Cardiology, Monaldi Hospital - "L. Vanvitelli" University, Naples, Italy
| | | | - Paolo Golino
- Department of Cardiology, Monaldi Hospital - "L. Vanvitelli" University, Naples, Italy
| | - Robert Naeije
- Department of Pathophysiology, Free University of Brussels, Brussels, Belgium
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Abstract
The most common cause of right heart failure is increased afterload caused by pulmonary hypertension. Right ventricular function adaptation to increased afterload is basically systolic, with secondary increase in dimensions and systemic congestion. Increased right ventricular dimensions and decreased ejection fraction are associated with a decreased survival in severe pulmonary hypertension. Targeted therapies titrated to reverse the right ventricular remodeling dimensions improve survival in severe pulmonary hypertension.
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Badagliacca R, Papa S, Poscia R, Pezzuto B, Manzi G, Torre R, Fedele F, Vizza CD. The importance of right ventricular function in patients with pulmonary arterial hypertension. Expert Rev Respir Med 2018; 12:809-815. [PMID: 30142003 DOI: 10.1080/17476348.2018.1515629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is a progressive, life-threatening, and incurable disease. Its prognosis is based on right ventricular (RV) function. Therefore, adequate assessment of RV function is mandatory. Areas covered: This article presents the case of a patient with PAH in which the traditional diagnostic approach did not provide a complete assessment of RV function. The authors show how the analysis of other parameters yielded additional information that improved the management of this patient. Expert commentary: Despite current treatments, PAH often worsens due to progressive RV dysfunction. Appropriate assessment of RV function may facilitate the early identification of patients at risk of RV function impairment. More aggressive treatment of PAH might delay progression of the disease. Traditional risk stratification, which is based on New York Heart Association/World Health Organization (NYHA/WHO) functional class evaluation, the 6-minute walk test, and right heart catheterization, proves insufficient in many PAH patients, as it does not provide complete information about RV function. Thus, further parameters are required. Analysis of RV function, in addition to echocardiography and cardiopulmonary exercise testing, may add relevant prognostic information and improve therapy.
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Affiliation(s)
- Roberto Badagliacca
- a Department of Cardiovascular and Respiratory Science , Sapienza University of Rome , Rome , Italy
| | - Silvia Papa
- a Department of Cardiovascular and Respiratory Science , Sapienza University of Rome , Rome , Italy
| | - Roberto Poscia
- a Department of Cardiovascular and Respiratory Science , Sapienza University of Rome , Rome , Italy
| | - Beatrice Pezzuto
- a Department of Cardiovascular and Respiratory Science , Sapienza University of Rome , Rome , Italy
| | - Giovanna Manzi
- a Department of Cardiovascular and Respiratory Science , Sapienza University of Rome , Rome , Italy
| | - Roberto Torre
- a Department of Cardiovascular and Respiratory Science , Sapienza University of Rome , Rome , Italy
| | - Francesco Fedele
- a Department of Cardiovascular and Respiratory Science , Sapienza University of Rome , Rome , Italy
| | - Carmine Dario Vizza
- a Department of Cardiovascular and Respiratory Science , Sapienza University of Rome , Rome , Italy
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Escribano-Subías P, Quezada-Loaiza CA. Role of right ventricular reverse remodeling in risk assessment of pulmonary hypertension. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2017.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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