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Harder EM, Divo MJ, Washko GR, Leopold JA, Rahaghi FN, Waxman AB. Implications of Mean Pulmonary Arterial Wedge Pressure Trajectories in Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2024; 209:316-324. [PMID: 37939220 PMCID: PMC10840771 DOI: 10.1164/rccm.202306-1072oc] [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] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/18/2023] [Indexed: 11/10/2023] Open
Abstract
Rationale: The mean pulmonary arterial wedge pressure (mPAWP) is the critical hemodynamic factor differentiating group 1 pulmonary arterial hypertension (PAH) from group 2 pulmonary hypertension associated with left heart disease. Despite the discrepancy between the mPAWP upper physiologic normal and current PAH definitions, the implications of the initial mPAWP for PAH clinical trajectory are poorly understood. Objectives: To model longitudinal mPAWP trajectories in PAH over 10 years and examine the clinical and hemodynamic factors associated with trajectory membership. Methods: Adult patients with PAH with two or more right heart catheterizations were identified from a multiinstitution healthcare system in eastern Massachusetts. mPAWP trajectories were constructed via group-based trajectory modeling. Feature selection was performed in least absolute shrinkage and selection operator regression. Logistic regression was used to assess associations between trajectory membership, baseline characteristics, and transplant-free survival. Measurements and Main Results: Among 301 patients with PAH, there were two distinct mPAWP trajectories, termed "mPAWP-high" (n = 71; 23.6%) and "mPAWP-low" (n = 230; 76.4%), based on the ultimate mPAWP value. Initial mPAWP clustered around median 12 mm Hg (interquartile range [IQR], 8-14 mm Hg) in the mPAWP-high and 9 mm Hg (IQR, 6-11 mm Hg) in the mPAWP-low trajectories (P < 0.001). After feature selection, initial mPAWP ⩾12 mm Hg predicted an mPAWP-high trajectory (odds ratio, 3.2; 95% confidence interval, 1.4-6.1; P = 0.0006). An mPAWP-high trajectory was associated with shorter transplant-free survival (vs. mPAWP-low, median, 7.8 vs. 11.3 yr; log-rank P = 0.017; age-adjusted P = 0.217). Conclusions: Over 10 years, the mPAWP followed two distinct trajectories, with 25% evolving into group 2 pulmonary hypertension physiology. Using routine baseline data, longitudinal mPAWP trajectory could be predicted accurately, with initial mPAWP ⩾12 mm Hg as one of the strongest predictors.
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Affiliation(s)
| | | | | | - Jane A. Leopold
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Zeng Y, Yu Q, Maimaitiaili N, Li B, Liu P, Hou Y, Mima, Cirenguojie, Sumit G, Dejizhuoga, Liu Y, Peng W. Clinical and Predictive Value of Computed Tomography Angiography in High-Altitude Pulmonary Hypertension. JACC. ASIA 2022; 2:803-815. [PMID: 36713752 PMCID: PMC9877215 DOI: 10.1016/j.jacasi.2022.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 12/15/2022]
Abstract
Background High-altitude pulmonary hypertension (HAPH), as the group 3 pulmonary hypertension, has been less studied so far. The limited medical conditions in the high-altitude plateau are responsible for the delay of the clinical management of HAPH. Objectives This study aims to identify the imaging characteristics of HAPH and explore noninvasive assessment of mean pulmonary arterial pressure (mPAP) based on computed tomography angiography (CTA). Methods Twenty-five patients with suspected HAPH were enrolled. Right heart catheterization (RHC) and pulmonary angiography were performed. Echocardiography and CTA image data were collected for analysis. A multivariable linear regression model was fit to estimate mPAP (mPAPpredicted). A Bland-Altman plot and pathological analysis were performed to assess the diagnostic accuracy of this model. Results Patients with HAPH showed slow blood flow and coral signs in lower lobe pulmonary artery in pulmonary arteriography, and presented trend for dilated pulmonary vessels, enlarged right atrium, and compressed left atrium in CTA (P for trend <0.05). The left lower pulmonary artery-bronchus ratio (odds ratio: 1.13) and the ratio of right to left atrial diameter (odds ratio: 1.09) were significantly associated with HAPH, and showed strong correlation with mPAPRHC, respectively (r = 0.821 and r = 0.649, respectively; all P < 0.0001). The mPAPpredicted model using left lower artery-bronchus ratio and ratio of right to left atrial diameter as covariates showed high correlation with mPAPRHC (r = 0.907; P < 0.0001). Patients with predicted HAPH also had the typical pathological changes of pulmonary hypertension. Conclusions Noninvasive mPAP estimation model based on CTA image data can accurately fit mPAPRHC and is beneficial for the early diagnosis of HAPH.
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Key Words
- ABR, pulmonary artery-bronchus ratio
- HAPH, high-altitude pulmonary hypertension
- LVEF, left ventricle ejection fraction
- PASP, pulmonary arterial systolic pressure
- PH, pulmonary hypertension
- RHC, right heart catheterization
- TRPG, tricuspid regurgitation pressure gradient
- computed tomography
- mPAP, mean pulmonary arterial pressure
- plateau
- pulmonary arterial pressure
- pulmonary artery-bronchus ratio
- rPA, the ratio of main pulmonary artery to aorta diameter
- rRLA, the ratio of right to left atrial diameter
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Affiliation(s)
- Yanxi Zeng
- Department of Cardiology, Shigatse People’s Hospital, Tibet, China,Department of Cardiology, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qing Yu
- Department of Cardiology, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Nuerbiyemu Maimaitiaili
- Department of Cardiology, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Bingyu Li
- Department of Cardiology, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Panjin Liu
- Department of Cardiology, Shigatse People’s Hospital, Tibet, China
| | - Yongzhi Hou
- Department of Ultrasound, Shigatse People’s Hospital, Tibet, China
| | - Mima
- Department of Cardiology, Shigatse People’s Hospital, Tibet, China
| | - Cirenguojie
- Department of Radiology, Shigatse People’s Hospital, Tibet, China
| | - Gupta Sumit
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dejizhuoga
- Department of Cardiology, Shigatse People’s Hospital, Tibet, China,Department of Cardiology, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yong Liu
- Department of Radiology, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China,Dr. Yong Liu, Department of Radiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, 301 Middle Yanchang Road, Shanghai 200072, China.
| | - Wenhui Peng
- Department of Cardiology, Shigatse People’s Hospital, Tibet, China,Department of Cardiology, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China,Address for correspondence: Dr Wenhui Peng, Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, 301 Middle Yanchang Road, Shanghai 200072, China.
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Brittain EL, Thenappan T, Huston JH, Agrawal V, Lai YC, Dixon D, Ryan JJ, Lewis EF, Redfield MM, Shah SJ, Maron BA. Elucidating the Clinical Implications and Pathophysiology of Pulmonary Hypertension in Heart Failure With Preserved Ejection Fraction: A Call to Action: A Science Advisory From the American Heart Association. Circulation 2022; 146:e73-e88. [PMID: 35862198 PMCID: PMC9901193 DOI: 10.1161/cir.0000000000001079] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This science advisory focuses on the need to better understand the epidemiology, pathophysiology, and treatment of pulmonary hypertension in patients with heart failure with preserved ejection fraction. This clinical phenotype is important because it is common, is strongly associated with adverse outcomes, and lacks evidence-based therapies. Our goal is to clarify key knowledge gaps in pulmonary hypertension attributable to heart failure with preserved ejection fraction and to suggest specific, actionable scientific directions for addressing such gaps. Areas in need of additional investigation include refined disease definitions and interpretation of hemodynamics, as well as greater insights into noncardiac contributors to pulmonary hypertension risk, optimized animal models, and further molecular studies in patients with combined precapillary and postcapillary pulmonary hypertension. We highlight translational approaches that may provide important biological insight into pathophysiology and reveal new therapeutic targets. Last, we discuss the current and future landscape of potential therapies for patients with heart failure with preserved ejection fraction and pulmonary vascular dysfunction, including considerations of precision medicine, novel trial design, and device-based therapies, among other considerations. This science advisory provides a synthesis of important knowledge gaps, culminating in a collection of specific research priorities that we argue warrant investment from the scientific community.
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Kianzad A, van Wezenbeek J, Celant LR, Oosterveer FP, Noordegraaf AV, Meijboom LJ, de Man FS, Bogaard HJ, Handoko ML. Idiopathic pulmonary arterial hypertension patients with a high H2FPEF-score: insights from the Amsterdam UMC PAH-cohort. J Heart Lung Transplant 2022; 41:1075-1085. [DOI: 10.1016/j.healun.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 04/19/2022] [Accepted: 05/08/2022] [Indexed: 10/18/2022] Open
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Leong K, Howard L, Lo Giudice F, Pavey H, Davies R, Haji G, Gibbs S, Gopalan D. MRI Feature Tracking Strain in Pulmonary Hypertension: Utility of Combined Left Atrial Volumetric and Deformation Assessment in Distinguishing Post- From Pre-capillary Physiology. Front Cardiovasc Med 2022; 9:787656. [PMID: 35369294 PMCID: PMC8968034 DOI: 10.3389/fcvm.2022.787656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
AimsPulmonary hypertension (PH) is dichotomized into pre- and post-capillary physiology by invasive catheterization. Imaging, particularly strain assessment, may aid in classification and be helpful with ambiguous hemodynamics. We sought to define cardiac MRI (CMR) feature tracking biatrial peak reservoir and biventricular peak systolic strain in pre- and post-capillary PH and examine the performance of peak left atrial strain in distinguishing the 2 groups compared to TTE.Methods and ResultsRetrospective cross-sectional study from 1 Jan 2015 to 31 Dec 2020; 48 patients (22 pre- and 26 post-capillary) were included with contemporaneous TTE, CMR and catheterization. Mean pulmonary artery pressures were higher in the pre-capillary cohort (55 ± 14 vs. 42 ± 9 mmHg; p < 0.001) as was pulmonary vascular resistance (median 11.7 vs. 3.7 WU; p < 0.001). Post-capillary patients had significantly larger left atria (60 ± 22 vs. 25 ± 9 ml/m2; p < 0.001). There was no difference in right atrial volumes between groups (60 ± 21 vs. 61 ± 29 ml/m2; p = 0.694), however peak RA strain was lower in post-capillary PH patients (8.9 ± 5.5 vs. 18.8 ± 7.0%; p < 0.001). In the post-capillary group, there was commensurately severe peak strain impairment in both atria (LA strain 9.0 ± 5.8%, RA strain 8.9 ± 5.5%). CMR LAVi and peak LA strain had a multivariate AUC of 0.98 (95% CI 0.89–1.00; p < 0.001) for post-capillary PH diagnosis which was superior to TTE.ConclusionCMR volumetric and deformation assessment of the left atrium can highly accurately distinguish post- from pre-capillary PH.
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Affiliation(s)
- Kai'En Leong
- Department of Radiology, Imperial College National Health Service Trust/Hammersmith Hospital, London, United Kingdom
- Department of Cardiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Luke Howard
- National Pulmonary Hypertension Service, Imperial College National Health Service Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Francesco Lo Giudice
- National Pulmonary Hypertension Service, Imperial College National Health Service Trust, London, United Kingdom
- Department of Cardiology, Imperial College National Health Service Trust/Hammersmith Hospital, London, United Kingdom
| | - Holly Pavey
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, United Kingdom
| | - Rachel Davies
- National Pulmonary Hypertension Service, Imperial College National Health Service Trust, London, United Kingdom
| | - Gulammehdi Haji
- National Pulmonary Hypertension Service, Imperial College National Health Service Trust, London, United Kingdom
| | - Simon Gibbs
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Deepa Gopalan
- Department of Radiology, Imperial College National Health Service Trust/Hammersmith Hospital, London, United Kingdom
- Department of Radiology, Cambridge University Hospitals National Health Service Trust, Cambridge, United Kingdom
- *Correspondence: Deepa Gopalan
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Jenei C, Kádár R, Balogh L, Borbély A, Győry F, Péter A, Daragó A, Csanádi Z. Role of 3D echocardiography-determined atrial volumes in distinguishing between pre-capillary and post-capillary pulmonary hypertension. ESC Heart Fail 2021; 8:3975-3983. [PMID: 34184427 PMCID: PMC8497217 DOI: 10.1002/ehf2.13496] [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: 01/15/2021] [Revised: 05/03/2021] [Accepted: 06/16/2021] [Indexed: 11/10/2022] Open
Abstract
Aims The current guidelines on pulmonary hypertension (PH) recommend the use of invasive examination for differentiating between left‐sided heart disease‐related (post‐capillary) and pre‐capillary PH. However, atrial sizes are considered markers of ventricular filling pressures. Therefore, we aimed to test the clinical applicability of atrial volumes measured by transthoracic three‐dimensional echocardiography (3DE) in differentiating between pre‐capillary and post‐capillary PH. Methods and results Seventy‐five consecutive patients with PH were prospectively examined with transthoracic 3DE. After less than 24 h, the patients underwent right heart catheterization and 3DE and were classified as pre‐capillary or post‐capillary PH according to the recommendations of the ESC guidelines. The atrial volumes were measured offline with dedicated commercial software. Thirty‐eight patients (13 men, age 65 ± 18 year) had pre‐capillary PH, and 37 (23 men, age 62 ± year) had post‐capillary PH. The mean pulmonary artery pressures were similar in patients with pre‐capillary and post‐capillary PH (38 [IQR 26, 54] mmHg vs. 41 [IQR 33, 48] mmHg, respectively, P = 0.49). The left atrial indexed maximum (LAVi max) and minimum (LAVi min) volumes were significantly larger in the post‐capillary PH patient group than in the pre‐capillary PH patient group (LAVi max: 64 ± 32 mL/m2 vs. 41 ± 25 mL/m2, P = 0.001; LAVi min: 50 ± 22 mL/m2 vs. 26 ± 24 mL/m2, P < 0.0001). The indexed right atrial minimum volume (RAVi min) was also higher in patients with post‐capillary PH (51 ± 27 mL/m2 vs. 38 ± 26 mL/m2; P = 0.02). Both the left atrial (LA) and right atrial (RA) volumes, especially the LA minimum volume, correlated with the pulmonary artery wedge pressure (PAWP) (r = 0.62 (P < 0.0001) for LAV min vs. r = 0.49 (P < 0.0001) for LAV max; r = 0.32 (P = 0.005) for RAV min vs. r = 0.24 (P = 0.04) for RAV max). Multivariate logistic regression analysis showed that LAVi min was an independent predictor of post‐capillary PH. In the receiver operating characteristic (ROC) curves of parameters predicting the post‐capillary PH, the areas under the curve (AUC) for LAVi min, LAVi max, and RAVi min were 0.86 (95% CI, 0.76–0.95), 0.78 (95% CI, 0.67–0.89), and 0.66 (0.53–0.78), respectively. Concerning the performance of the atrial volume ratio for differentiating post‐capillary PH, the AUC of the atrial volume ratio was significantly lower [AUC: 0.66 (95% CI, 0.53–0.78)]. The ROC analysis indicated a possible cutoff value of 27.7 mL/m2 for LAVi min to predict post‐capillary PH (AUC = 0.86; sensitivity = 86%, specificity = 76%). Conclusions The BSA‐indexed left atrial minimum volume measured by transthoracic 3DE is a useful parameter for differentiating pre‐capillary from post‐capillary pulmonary hypertension.
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Affiliation(s)
- Csaba Jenei
- Department of Cardiology and Cardiac Surgery, University of Debrecen, Debrecen, Hungary
| | - Rebeka Kádár
- Department of Radiology (Medical Imaging Clinic), University of Debrecen, Debrecen, Hungary
| | - László Balogh
- Department of Cardiology and Cardiac Surgery, University of Debrecen, Debrecen, Hungary
| | - Attila Borbély
- Department of Cardiology and Cardiac Surgery, University of Debrecen, Debrecen, Hungary
| | - Ferenc Győry
- Department of Cardiology and Cardiac Surgery, University of Debrecen, Debrecen, Hungary
| | - Andrea Péter
- Department of Cardiology and Cardiac Surgery, University of Debrecen, Debrecen, Hungary
| | - Andrea Daragó
- Department of Cardiology and Cardiac Surgery, University of Debrecen, Debrecen, Hungary
| | - Zoltán Csanádi
- Department of Cardiology and Cardiac Surgery, University of Debrecen, Debrecen, Hungary
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Cardiac Magnetic Resonance-Derived Indexed Volumes and Volume Ratios of the Cardiac Chambers Discriminating Group 2 Pulmonary Hypertension From Other World Health Organization Groups. J Comput Assist Tomogr 2021; 45:59-64. [PMID: 32976268 DOI: 10.1097/rct.0000000000001058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aims of the study were to assess the performance of cardiac magnetic resonance (CMR)-derived cardiac chamber volumes and volume ratios to identify group 2 pulmonary hypertension (PH) patients and to determine their cutoff values with the highest sensitivity and specificity. METHODS One hundred six patients underwent CMR, 2 months after the diagnosis of PH by right heart catheterization. We classified patients with pulmonary capillary wedge pressure of greater than 15 mm Hg as group 2 PH. Cardiac chamber volumes indexed to the body surface area and volume ratios were correlated to the type of PH. Their sensitivity and specificity to detect group 2 PH were examined at various cutoff points. RESULTS The most appropriate cutoff values to designate group 2 PH patients with high sensitivity and specificity were as follows: left atrium volume index of 54.72 mL/m2 or greater, right ventricle volume/left atrium volume of 2.07 or less, and right atrium volume/left atrium volume of 1.61 or less. CONCLUSIONS Cardiac magnetic resonance-derived cardiac chamber volume indices and volume ratios can determine group 2 PH diagnosis with high sensitivity and specificity.
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Pediatric lung transplantation in the largest lung transplantation center of China: embarking on a long road. Sci Rep 2020; 10:12471. [PMID: 32719472 PMCID: PMC7385630 DOI: 10.1038/s41598-020-69340-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 07/08/2020] [Indexed: 12/17/2022] Open
Abstract
Lung transplantation (LT) has been an effective treatment for carefully selected children with end-stage lung diseases. The aim of this retrospective study is to introduce our experience at the largest LT center in Wuxi, China and to compare the outcomes of pediatric LT between children with idiopathic pulmonary arterial hypertension (IPAH) and other end-stage lung diseases. Ten pediatric patients undergoing LT from 2007 to 2019 were included. Sequential bilateral lung transplantation (BLT) with bilateral anterior thoracotomies was performed in all patients, seven of whom also underwent reduced size LT. Eight children survived until the end of our follow-up period on July 31st, 2019, with the longest survival of 11 years. Extracorporeal membrane oxygenation (ECMO) was intraoperatively used in all IPAH children and one non-IPAH child. Left heart function of IPAH children, though initially compromised, recovered after surgery. Statistically significant differences in operation time and post-operative mechanical ventilation between IPAH group and non-IPAH group were observed without discernible impact on post-LT survival. Pediatric LT appears to be a safe treatment for IPAH children to improve longevity and quality of life and ECMO may help reduce the risk of surgery and the postoperative complications.
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Kiely DG, Levin DL, Hassoun PM, Ivy D, Jone PN, Bwika J, Kawut SM, Lordan J, Lungu A, Mazurek JA, Moledina S, Olschewski H, Peacock AJ, Puri G, Rahaghi FN, Schafer M, Schiebler M, Screaton N, Tawhai M, van Beek EJ, Vonk-Noordegraaf A, Vandepool R, Wort SJ, Zhao L, Wild JM, Vogel-Claussen J, Swift AJ. EXPRESS: Statement on imaging and pulmonary hypertension from the Pulmonary Vascular Research Institute (PVRI). Pulm Circ 2019; 9:2045894019841990. [PMID: 30880632 PMCID: PMC6732869 DOI: 10.1177/2045894019841990] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 03/01/2019] [Indexed: 01/08/2023] Open
Abstract
Pulmonary hypertension (PH) is highly heterogeneous and despite treatment advances it remains a life-shortening condition. There have been significant advances in imaging technologies, but despite evidence of their potential clinical utility, practice remains variable, dependent in part on imaging availability and expertise. This statement summarizes current and emerging imaging modalities and their potential role in the diagnosis and assessment of suspected PH. It also includes a review of commonly encountered clinical and radiological scenarios, and imaging and modeling-based biomarkers. An expert panel was formed including clinicians, radiologists, imaging scientists, and computational modelers. Section editors generated a series of summary statements based on a review of the literature and professional experience and, following consensus review, a diagnostic algorithm and 55 statements were agreed. The diagnostic algorithm and summary statements emphasize the key role and added value of imaging in the diagnosis and assessment of PH and highlight areas requiring further research.
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Affiliation(s)
- David G. Kiely
- Sheffield Pulmonary Vascular Disease
Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
| | - David L. Levin
- Department of Radiology, Mayo Clinic,
Rochester, MN, USA
| | - Paul M. Hassoun
- Department of Medicine John Hopkins
University, Baltimore, MD, USA
| | - Dunbar Ivy
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | - Pei-Ni Jone
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | | | - Steven M. Kawut
- Department of Medicine, Perelman School
of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jim Lordan
- Freeman Hospital, Newcastle Upon Tyne,
Newcastle, UK
| | - Angela Lungu
- Technical University of Cluj-Napoca,
Cluj-Napoca, Romania
| | - Jeremy A. Mazurek
- Division of Cardiovascular Medicine,
Hospital
of the University of Pennsylvania,
Philadelphia, PA, USA
| | | | - Horst Olschewski
- Division of Pulmonology, Ludwig
Boltzmann Institute Lung Vascular Research, Graz, Austria
| | - Andrew J. Peacock
- Scottish Pulmonary Vascular Disease,
Unit, University of Glasgow, Glasgow, UK
| | - G.D. Puri
- Department of Anaesthesiology and
Intensive Care, Post Graduate Institute of Medical Education and Research,
Chandigarh, India
| | - Farbod N. Rahaghi
- Brigham and Women’s Hospital, Harvard
Medical School, Boston, MA, USA
| | - Michal Schafer
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | - Mark Schiebler
- Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Merryn Tawhai
- Auckland Bioengineering Institute,
Auckland, New Zealand
| | - Edwin J.R. van Beek
- Edinburgh Imaging, Queens Medical
Research Institute, University of Edinburgh, Edinburgh, UK
| | | | - Rebecca Vandepool
- University of Arizona, Division of
Translational and Regenerative Medicine, Tucson, AZ, USA
| | - Stephen J. Wort
- Royal Brompton Hospital, London,
UK
- Imperial College, London, UK
| | | | - Jim M. Wild
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
- Academic Department of Radiology,
University of Sheffield, Sheffield, UK
| | - Jens Vogel-Claussen
- Institute of diagnostic and
Interventional Radiology, Medical Hospital Hannover, Hannover, Germany
| | - Andrew J. Swift
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
- Academic Department of Radiology,
University of Sheffield, Sheffield, UK
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Hur DJ, Sugeng L. Non-invasive Multimodality Cardiovascular Imaging of the Right Heart and Pulmonary Circulation in Pulmonary Hypertension. Front Cardiovasc Med 2019; 6:24. [PMID: 30931315 PMCID: PMC6427926 DOI: 10.3389/fcvm.2019.00024] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 02/20/2019] [Indexed: 12/13/2022] Open
Abstract
Pulmonary hypertension (PH) is defined as resting mean pulmonary arterial pressure (mPAP) ≥25 millimeters of mercury (mmHg) via right heart (RH) catheterization (RHC), where increased afterload in the pulmonary arterial vasculature leads to alterations in RH structure and function. Mortality rates have remained high despite therapy, however non-invasive imaging holds the potential to expedite diagnosis and lead to earlier initiation of treatment, with the hope of improving prognosis. While historically the right ventricle (RV) had been considered a passive chamber with minimal role in the overall function of the heart, in recent years in the evaluation of PH and RH failure the anatomical and functional assessment of the RV has received increased attention regarding its performance and its relationship to other structures in the RH-pulmonary circulation. Today, the RV is the key determinant of patient survival. This review provides an overview and summary of non-invasive imaging methods to assess RV structure, function, flow, and tissue characterization in the setting of imaging's contribution to the diagnostic, severity stratification, prognostic risk, response of treatment management, and disease surveillance implications of PH's impact on RH dysfunction and clinical RH failure.
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Affiliation(s)
- David J Hur
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States.,Division of Cardiology, Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States
| | - Lissa Sugeng
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States.,Echocardiography Laboratory, Yale New Haven Hospital, New Haven, CT, United States
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11
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Lai YC, Wang L, Gladwin MT. Insights into the pulmonary vascular complications of heart failure with preserved ejection fraction. J Physiol 2018; 597:1143-1156. [PMID: 30549058 DOI: 10.1113/jp275858] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 11/19/2018] [Indexed: 12/21/2022] Open
Abstract
Pulmonary hypertension in the setting of heart failure with preserved ejection fraction (PH-HFpEF) is a growing public health problem that is increasing in prevalence. While PH-HFpEF is defined by a high mean pulmonary artery pressure, high left ventricular end-diastolic pressure and a normal ejection fraction, some HFpEF patients develop PH in the presence of pulmonary vascular remodelling with a high transpulmonary pressure gradient or pulmonary vascular resistance. Ageing, increased left atrial pressure and stiffness, mitral regurgitation, as well as features of metabolic syndrome, which include obesity, diabetes and hypertension, are recognized as risk factors for PH-HFpEF. Qualitative studies have documented that patients with PH-HFpEF develop more severe symptoms than those with HFpEF and are associated with more significant exercise intolerance, frequent hospitalizations, right heart failure and reduced survival. Currently, there are no effective therapies for PH-HFpEF, although a number of candidate drugs are being evaluated, including soluble guanylate cyclase stimulators, phosphodiesterase type 5 inhibitors, sodium nitrite and endothelin receptor antagonists. In this review we attempt to provide an updated overview of recent findings pertaining to the pulmonary vascular complications in HFpEF in terms of clinical definitions, epidemiology and pathophysiology. Mechanisms leading to pulmonary vascular remodelling in HFpEF, a summary of pre-clinical models of HFpEF and PH-HFpEF, and new candidate therapeutic strategies for the treatment of PH-HFpEF are summarized.
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Affiliation(s)
- Yen-Chun Lai
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Longfei Wang
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA.,The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA.,Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Bredfelt A, Rådegran G, Hesselstrand R, Arheden H, Ostenfeld E. Increased right atrial volume measured with cardiac magnetic resonance is associated with worse clinical outcome in patients with pre-capillary pulmonary hypertension. ESC Heart Fail 2018; 5:864-875. [PMID: 29916558 PMCID: PMC6165945 DOI: 10.1002/ehf2.12304] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 04/04/2018] [Accepted: 04/16/2018] [Indexed: 11/23/2022] Open
Abstract
AIMS Pre-capillary pulmonary hypertension (PHpre-cap ) has a poor prognosis, especially when caused by pulmonary arterial hypertension (PAH) associated with systemic sclerosis (SSc-PAH). Whether cardiac magnetic resonance (CMR)-based quantification of atrial volumes in PHpre-cap is beneficial in risk assessment is unknown. The aims were to investigate if (i) atrial volumes using CMR are associated with death or lung transplantation in PHpre-cap , (ii) atrial volumes differ among four unmatched major PHpre-cap subgroups, and (iii) atrial volumes differ between SSc-PAH and idiopathic/familial PAH (IPAH/FPAH) when matched for pulmonary vascular resistance (PVR). METHODS AND RESULTS Seventy-five PHpre-cap patients (57 ± 19 years, 53 female, 43 de novo) with CMR and right heart catheterization were retrospectively included. Short-axis stacks of cine images were analysed, and right and left atrial maximum (RAVmax and LAVmax ) and minimum volume (RAVmin and LAVmin ) were indexed for body surface area. Increased (mean + 2 SD) and reduced (mean - 2 SD) volumes were predefined from CMR normal values. Transplantation-free survival was lower in patients with increased RAVmax than in those with normal [hazard ratio (HR) = 2.1, 95% confidence interval (CI) 1.1-4.0] but did not differ between those with reduced LAVmax and normal (HR 2.0, 95% CI 0.8-5.1). RAVmax and RAVmin showed no differences among unmatched or matched groups (P = ns). When matched for PVR, LAVmax , LAVmin , and pulmonary artery wedge pressure were reduced in SSc-PAH compared with IPAH/FPAH (95% CI 0.3-21.4, 95% CI 0.8-19.6, and 95% CI 2-7, respectively). CONCLUSIONS Patients with PHpre-cap and increased right atrial volume measured with CMR had worse clinical outcome. When matched for PVR, left atrial volume was lower in SSc-PAH than in IPAH/FPAH, consistent with left-sided underfilling, indicating a potential differentiator between the groups.
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Affiliation(s)
- Anna Bredfelt
- Department of Clinical Sciences Lund, Clinical PhysiologyLund UniversityLundSweden
- Department of Clinical Physiology and Nuclear ImagingSkåne University HospitalGetingevägen 5SE‐22185LundSweden
| | - Göran Rådegran
- Department of Clinical Sciences Lund, CardiologyLund UniversityLundSweden
- The Section for Heart Failure and Valvular Disease, VO Heart and Lung MedicineSkåne University HospitalLundSweden
| | - Roger Hesselstrand
- Department of Clinical Sciences Lund, RheumatologyLund UniversityLundSweden
- Skåne University HospitalLundSweden
| | - Håkan Arheden
- Department of Clinical Sciences Lund, Clinical PhysiologyLund UniversityLundSweden
- Department of Clinical Physiology and Nuclear ImagingSkåne University HospitalGetingevägen 5SE‐22185LundSweden
| | - Ellen Ostenfeld
- Department of Clinical Sciences Lund, Clinical PhysiologyLund UniversityLundSweden
- Department of Clinical Physiology and Nuclear ImagingSkåne University HospitalGetingevägen 5SE‐22185LundSweden
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Vieillard-Baron A, Naeije R, Haddad F, Bogaard HJ, Bull TM, Fletcher N, Lahm T, Magder S, Orde S, Schmidt G, Pinsky MR. Diagnostic workup, etiologies and management of acute right ventricle failure : A state-of-the-art paper. Intensive Care Med 2018; 44:774-790. [PMID: 29744563 DOI: 10.1007/s00134-018-5172-2] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 04/07/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION This is a state-of-the-art article of the diagnostic process, etiologies and management of acute right ventricular (RV) failure in critically ill patients. It is based on a large review of previously published articles in the field, as well as the expertise of the authors. RESULTS The authors propose the ten key points and directions for future research in the field. RV failure (RVF) is frequent in the ICU, magnified by the frequent need for positive pressure ventilation. While no universal definition of RVF is accepted, we propose that RVF may be defined as a state in which the right ventricle is unable to meet the demands for blood flow without excessive use of the Frank-Starling mechanism (i.e. increase in stroke volume associated with increased preload). Both echocardiography and hemodynamic monitoring play a central role in the evaluation of RVF in the ICU. Management of RVF includes treatment of the causes, respiratory optimization and hemodynamic support. The administration of fluids is potentially deleterious and unlikely to lead to improvement in cardiac output in the majority of cases. Vasopressors are needed in the setting of shock to restore the systemic pressure and avoid RV ischemia; inotropic drug or inodilator therapies may also be needed. In the most severe cases, recent mechanical circulatory support devices are proposed to unload the RV and improve organ perfusion CONCLUSION: RV function evaluation is key in the critically-ill patients for hemodynamic management, as fluid optimization, vasopressor strategy and respiratory support. RV failure may be diagnosed by the association of different devices and parameters, while echocardiography is crucial.
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Affiliation(s)
- Antoine Vieillard-Baron
- Service de Réanimation, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 92100, Boulogne-Billancourt, France.
- INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France.
| | - R Naeije
- Professor Emeritus at the Université Libre de Bruxelles, Brussels, Belgium
| | - F Haddad
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford, USA
| | - H J Bogaard
- Department of Pulmonary Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - T M Bull
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - N Fletcher
- Department of Cardiothoracic Critical Care, St Georges University Hospital NHS Trust, London, SW17 0QT, UK
| | - T Lahm
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - S Magder
- Department of Critical Care, McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - S Orde
- Intensive Care Unit, Nepean Hospital, Kingswood, Sydney, NSW, Australia
| | - G Schmidt
- Department of Internal Medicine and Critical Care, University of Iowa, Iowa City, USA
| | - M R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
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