The Relationship Between Pulmonary Artery and Pulmonary Capillary Wedge Pressure for the Diagnosis of Pulmonary Vascular Disease

Pulmonary hypertension and congenital bronchial atresia: A time factor association

Congenital bronchial atresia is rarely symptomatic in adults. Recurrent lung infection and pneumothorax are the feared complications of this otherwise benign condition. The objective of this article is to present a case of congenital bronchial atresia manifesting as pulmonary hypertension in a 66 year-old patient. While doing so, we highlight the relevant knowledge accrued in medical literature with regards this rare condition. Finally, with the revelation that congenital bronchial atresia may cause severe pulmonary hypertension later in life, perhaps a less conservative approach to management may be warranted in younger adults and children with this condition.

Pulmonary Arterial Hypertension Specific Therapy in Patients with Combined Post- and Precapillary Pulmonary Hypertension

Background

Specific therapy for patients with PAH is associated with good outcomes. Little is known about the effect of this treatment in patients with Cpc-PH (PAPm ≥ 25 mmHg, PAWP > 15 mmHg, DPG ≥ 7 mmHg, and/or PVR > 3 WU). This study evaluates the outcome of treating patients with Cpc-PH using PAH specific therapy.

Methods

The primary outcome was survival. Secondary outcomes were WHO functional class and 6-minute walk distance (6-MWD).

Results

Twenty-six patients with Cpc-PH (half with VHD and half with HF) received PAHST. Six patients did not tolerate treatment due to pulmonary edema. No predictors for treatment intolerance were identified. In twenty patients who tolerated the treatment, the mean WHO functional class improved from 2.70 ± 0.21 at initial assessment to 2.22 ± 0.21 (p < 0.04) and 2.06 ± 0.21 (p < 0.03) at 6 and 9 months, respectively. Mean 6-MWD improved from 276.0 ± 38.50 meters at initial assessment to 343.9 ± 22.99 meters (p < 0.04) and 364.6 ± 34.85 meters (p = 0.07) at 6 and 9 months, respectively. Twelve patients died during the follow-up period. Mean survival for all patients was 1279.7 ± 193.60 days.

Conclusion

PAHST may be beneficial in the treatment of Cpc-PH (both short and long term). Prospective randomized controlled trials of PAHST in this population are needed to assess its potential efficacy.

Non-Invasive Lung IMPEDANCE-Guided Preemptive Treatment in Chronic Heart Failure Patients: A Randomized Controlled Trial (IMPEDANCE-HF Trial)

BACKGROUND

Previous investigations have suggested that lung impedance (LI)-guided treatment reduces hospitalizations for acute heart failure (AHF). A single-blind 2-center trial was performed to evaluate this hypothesis (ClinicalTrials.gov-NCT01315223).

METHODS

The study population included 256 patients from 2 medical centers with chronic heart failure and left ventricular ejection fraction ≤35% in New York Heart Association class II-IV, who were admitted for AHF within 12 months before recruitment. Patients were randomized to a control group treated by clinical assessment and a monitored group whose therapy was also assisted by LI, and followed for at least 12 months. Noninvasive LI measurements were performed with a new high-sensitivity device. Patients, blinded to their assignment group, were scheduled for monthly visits in the outpatient clinics. The primary efficacy endpoint was AHF hospitalizations; the secondary endpoints were all-cause hospitalizations and mortality.

RESULTS

There were 67 vs 158 AHF hospitalizations during the first year (P < .001) and 211 vs 386 AHF hospitalizations (P < .001) during the entire follow-up among the monitored patients (48 ± 32 months) and control patients (39 ± 26 months, P = .01), respectively. During the follow-up, there were 42 and 59 deaths (hazard ratio 0.52, 95% confidence interval 0.35-0.78, P = .002) with 13 and 31 of them resulting from heart failure (hazard ratio 0.30, 95% confidence interval 0.15-0.58 P < .001) in the monitored and control groups, respectively. The incidence of noncardiovascular death was similar.

CONCLUSION

Our results seem to validate the concept that LI-guided preemptive treatment of chronic heart failure patients reduces hospitalizations for AHF as well as the incidence of heart failure, cardiovascular, and all-cause mortality.

Management of pulmonary hypertension in left heart disease

Pulmonary hypertension (PH) due to left heart disease is classified as group II according to the Dana Point classification, which includes left ventricular systolic and/or diastolic left heart failure, and left-sided valvular disease. PH due to left heart disease is the most common cause and when present, especially with right ventricular dysfunction, is associated with a worse prognosis. Left heart disease with secondary PH is associated with increased left atrial pressure, which causes a passive increase in pulmonary pressure. Passive PH could be superimposed by an active protective, and in some patients by an ‘out of proportion’, elevated precapillary pulmonary vasoconstriction and vascular remodelling which leads to greater or lesser further increase of the pulmonary artery pressure. In this review, epidemiological and pathophysiologic mechanisms for the development of group II PH are summarized. The conflicting data about the haemodynamic and possible parameters to diagnose passive versus reactive and ‘out of proportion’ PH are presented. The different therapeutic concepts, along with novel treatment strategies, are reviewed in detail and critically discussed regarding their effectiveness and safety.