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Nabeshima Y, Kitano T, Node K, Takeuchi M. Prognostic value of right ventricular free-wall longitudinal strain in patients with pulmonary hypertension: systematic review and meta-analyses. Open Heart 2024; 11:e002561. [PMID: 38325907 PMCID: PMC10860115 DOI: 10.1136/openhrt-2023-002561] [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: 11/23/2023] [Accepted: 01/18/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND Right ventricular (RV) dysfunction is associated with adverse outcomes in patients with pulmonary hypertension (PH). This systematic review and meta-analysis evaluated the prognostic value of RV free-wall longitudinal strain (RVfwLS), compared with other RV parameters in PH. METHODS We searched for articles presenting the HR of two-dimensional RVfwLS in PH. HRs were standardised using the within-study SD. The ratio of HRs of a 1 SD change in RVfwLS versus systolic pulmonary arterial pressure (SPAP), systolic tricuspid annular velocities (s'-TV), RV fractional area change (FAC) or tricuspid annular plane systolic excursion (TAPSE) was calculated for each study, after which we conducted a random model meta-analysis. Subgroup analysis regarding the type of outcome, aetiology of PH and software vendor was also performed. RESULTS Twenty articles totalling 2790 subjects were included. The pooled HR of a 1 SD decrease of RVfwLS was 1.80 (95% CI: 1.62 to 2.00, p<0.001), and there was a significant association with all-cause death (ACD) and composite endpoints (CEs). The ratio of HR analysis revealed that RVfwLS has a significant, strong association with ACD and CE per 1 SD change, compared with corresponding values of SPAP, s'-TV, RVFAC or TAPSE. RVfwLS was a significant prognostic factor regardless of the aetiology of PH. However, significant superiority of RVfwLS versus other parameters was not observed in group 1 PH. CONCLUSIONS The prognostic value of RVfwLS in patients with PH was confirmed, and RVfwLS is better than other RV parameters and SPAP. Further accumulation of evidence is needed to perform a detailed subgroup analysis for each type of PH. TRIAL REGISTRATION NUMBER UMIN Clinical Trials Registry (UMIN000052679).
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Affiliation(s)
- Yosuke Nabeshima
- Department of Cardiovascular Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Tetsuji Kitano
- University of Occupational and Environmental Health Japan, Kitakyushu, Fukuoka, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, University of Occupational and Environmental Health Hospital, Kitakyushu, Fukuoka, Japan
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2
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Li X, Yang T, Zhang Y, Zhao Q, Zeng Q, Jin Q, Duan A, Huang Z, Hu M, Zhang S, Gao L, Xiong C, Luo Q, Zhao Z, Liu Z. Optimal short-term outcomes in balloon pulmonary angioplasty: the minimum frequency of three sessions annually. Ther Adv Respir Dis 2024; 18:17534666241232521. [PMID: 38409856 PMCID: PMC10898305 DOI: 10.1177/17534666241232521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 01/29/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Balloon pulmonary angioplasty (BPA) is typically performed in a sequential manner. OBJECTIVES This study aimed to determine the lowest frequency of BPA for patients who could not reach treatment goals in a short period. DESIGN Retrospective cohort. METHODS We retrospectively enrolled 186 BPA-treated patients diagnosed with chronic thromboembolic pulmonary hypertension. According to the accumulative number of performed BPA sessions or treated pulmonary vessels or the ratio of the number of treated pulmonary vessels/the number of baseline lesions (T/P) prior to the initial occurrence of clinical outcome or censored date, we divided patients into different groups. The principal outcome was clinical worsening. RESULTS After stratifying patients by the number of performed BPA sessions, most baseline parameters were comparable among groups. During follow-up, 31 (16.7%) of 186 patients experienced clinical worsening. The 6-month cumulative clinical worsening-free survival rates of ⩾2 performed sessions group were significantly higher than that of 1 performed session group. The 12-month cumulative rates of clinical worsening-free survival exhibited a declining pattern in the subsequent sequence: ⩾3, 2, and 1 performed BPA sessions, and this trend persisted when follow-up time exceeded 12 months. The 6-, 12-, and 24-month cumulative clinical worsening-free survival rates were comparable between patients with 3 and ⩾4 performed BPA sessions. Similar results were also observed when stratifying patients by the accumulative number of treated pulmonary vessels (⩽8, 9-16, ⩾17) and T/P (⩽0.789, 0.790-1.263, ⩾1.264). CONCLUSION To achieve optimal short-term outcomes, patients might need to undergo ⩾2 BPA sessions or have ⩾9 pulmonary vessels treated or have T/P ⩾0.790 within 6 months, and undergo ⩾3 BPA sessions or have ⩾17 pulmonary vessels treated or have T/P ⩾1.264 within 12 months.
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Affiliation(s)
- Xin Li
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Tao Yang
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Yi Zhang
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
- Department of ICU, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Qing Zhao
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Qixian Zeng
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Qi Jin
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Anqi Duan
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Zhihua Huang
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Meixi Hu
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Sicheng Zhang
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Luyang Gao
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Changming Xiong
- Center for Respiratory and Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Zhihui Zhao
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing 100037, China
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3
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Bartnik A, Pepke-Zaba J, Bunclark K, Ruggiero A, Jenkins D, Taghavi J, Tsui S, Screaton N, D'Errico L, Weir-McCall J. Cardiac MRI in the assessment of chronic thromboembolic pulmonary hypertension and response to treatment. Thorax 2023; 79:90-97. [PMID: 38050117 DOI: 10.1136/thorax-2022-219716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 10/31/2023] [Indexed: 12/06/2023]
Affiliation(s)
- Aleksandra Bartnik
- Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
- Radiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
- Radiology, University of Cambridge, Cambridge, UK
| | | | | | | | - D Jenkins
- Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - J Taghavi
- Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Steven Tsui
- Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | | | - L D'Errico
- Radiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Jonathan Weir-McCall
- Radiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
- Radiology, University of Cambridge, Cambridge, UK
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Kariki O, Karyofyllis P, Mililis P, Saplaouras A, Dragasis S, Chatziantoniou A, Alexiou D, Patsiotis IG, Letsas KP, Efremidis M. Electrocardiographic changes after balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension: Data from the Hellenic Registry. J Electrocardiol 2023; 81:26-31. [PMID: 37506539 DOI: 10.1016/j.jelectrocard.2023.07.006] [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: 04/26/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Balloon pulmonary angioplasty (BPA) has provided an effective invasive treatment for inoperable patients with chronic thromboembolic pulmonary hypertension (CTEPH). The hemodynamic improvement achieved by BPA has significantly increased the long-term prognosis of these patients, mostly by reversing the negative remodeling of the right ventricle (RV). MATERIALS AND METHODS In a cohort of 17 patients with symptomatic CTEPH hemodynamic data were collected before and after the completion of BPA sessions. After the confirmation of statistically significant hemodynamic improvement, we examined the changes in certain prespecified electrocardiographic (ECG) parameters (PR interval duration, QRS duration, QTc interval duration, R wave and S wave amplitude in lead I, R wave and S wave amplitude in precordial leads V1, V5 and V6) before the initiation and one month after the completion of BPA sessions. In addition, ECGs were qualitatively assessed before and after treatment for the presence of ECG abnormalities related to PH, proposed by the guidelines of the European Society of Cardiology (ESC). The term ESC criteria 1-6 was used for their description. RESULTS Statistically significant correlation (p < 0.05) was found between the reduction in mean pulmonary artery pressure (mPAP) and the decrease of the depth of the S wave in leads I (p 0.0069), V5 (p 0.0003), V6 (p 0.0011) and in the R wave amplitude in leads V5 (p 0.0122) and V6 (p 0.0185). From the ESC criteria, RV strain pattern was the commonest in the initial cohort, with significant improvement after therapies. CONCLUSION Hemodynamic improvement after BPA therapies is correlated with improved ECG amplitude parameters in leads I, V5 and V6. RV strain pattern is common among untreated patients with significant improvement after therapies.
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Affiliation(s)
- Ourania Kariki
- Division of Interventional Cardiology and Arrhythmia Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Panagiotis Karyofyllis
- Division of Interventional Cardiology and Arrhythmia Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Panagiotis Mililis
- Division of Interventional Cardiology and Arrhythmia Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Athanasios Saplaouras
- Division of Interventional Cardiology and Arrhythmia Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Stylianos Dragasis
- Division of Interventional Cardiology and Arrhythmia Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Anastasios Chatziantoniou
- Division of Interventional Cardiology and Arrhythmia Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Dimitris Alexiou
- Division of Interventional Cardiology and Arrhythmia Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Ilias G Patsiotis
- Division of Interventional Cardiology and Arrhythmia Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Konstantinos P Letsas
- Division of Interventional Cardiology and Arrhythmia Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece.
| | - Michael Efremidis
- Division of Interventional Cardiology and Arrhythmia Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece
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Ley L, Wiedenroth CB, Ghofrani HA, Hoeltgen R, Bandorski D. Analysis of Electrocardiographic Criteria of Right Ventricular Hypertrophy in Patients with Chronic Thromboembolic Pulmonary Hypertension before and after Balloon Pulmonary Angioplasty. J Clin Med 2023; 12:4196. [PMID: 37445229 DOI: 10.3390/jcm12134196] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 06/14/2023] [Accepted: 06/14/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) may lead to typical electrocardiographic changes that can be reversed by balloon pulmonary angioplasty (BPA). The aim of this study was to investigate the significance of rarely used electrocardiogram (ECG) parameters, possible electrocardiographic differences between residual and significantly improved CTEPH and the role of electrocardiographic parameters in low mPAP (mean pulmonary arterial pressure) ranges since the mPAP threshold for the definition of pulmonary hypertension has recently been adjusted (≥25 mmHg to >20 mmHg). MATERIAL AND METHODS Between March 2014 and October 2020, 140 patients with CTEPH and 10 with CTEPD (chronic thromboembolic pulmonary disease) without pulmonary hypertension (PH) were retrospectively enrolled (12-lead ECG and right heart catheterization before and 6 months after BPA). The ECG parameters of right heart strain validated by studies and clinical experience were evaluated. Special attention was paid to six specific ECG parameters. After BPA, the cohort was divided into subgroups to investigate possible electrocardiographic differences with regard to the haemodynamic result. RESULTS The present study confirmed that the typical electrocardiographic signs of CTEPH can be found on an ECG, can regress after BPA and partially correlate well with haemodynamic parameters. "R V1, V2 + S I, aVL - S V1" was a parameter of particular note. BPA reduced its frequency (47% vs. 29%) statistically significantly after Bonferroni correction (p < 0.001). Moreover, it showed a good correlation with mPAP and PVR (r-values: 0.372-0.519, p-values: < 0.001). Exceeding its cut-off value before therapy was associated with more severe CTEPH before therapy (higher mPAP, PVR, NT-pro-BNP and troponin and lower TAPSE) and an increased risk of death. Exceeding its cut-off value before and after therapy was associated with more severe CTEPH after therapy (higher RAP, mPAP, PVR, NT-pro-BNP and NYHA class) and an increased risk of death. Men tend to be affected more frequently. After subgrouping, it was observed that a higher median mPAP was associated with a higher right atrial pressure (RAP), a higher pulmonary vascular resistance (PVR) and a lower cardiac output (CO) before and after BPA. In addition, under these conditions, more and more severe electrocardiographic pathologies were detected before and after BPA. Some patients with low mPAP also continued to show mild ECG changes after BPA. In some cases, very few to no pathological ECG changes were detected, and the ECG could present as mostly normal in some patients (5% before BPA and 13% after BPA). CONCLUSION "R V1, V2 + S I, aVL - S V1" seems to be able to support the diagnosis of CTEPH, indicate therapeutic improvement and estimate haemodynamics. It also seems capable of predicting a (persistent) severe disease with probably increased need for therapy and increased mortality. Mild PH has been observed to have either no or few mild ECG changes. This might complicate the (early) detection of PH.
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Affiliation(s)
- Lukas Ley
- Campus Kerckhoff, Justus-Liebig-University Giessen, 61231 Bad Nauheim, Germany
| | - Christoph B Wiedenroth
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, 61231 Bad Nauheim, Germany
| | | | | | - Dirk Bandorski
- Faculty of Medicine, Semmelweis University Campus Hamburg, 20099 Hamburg, Germany
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6
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Electrocardiogram in patients with pulmonary hypertension. J Electrocardiol 2023; 79:24-29. [PMID: 36913785 DOI: 10.1016/j.jelectrocard.2023.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023]
Abstract
INTRODUCTION Pulmonary hypertension (PH) is a potentially life-threatening cardiovascular disease defined by a mean pulmonary arterial pressure (mPAP) > 20 mmHg. Due to non-specific symptoms, PH is often diagnosed late and at advanced stage. In addition to other diagnostic modalities, the electrocardiogram (ECG) can help in establishing the diagnosis. Knowledge of typical ECG signs could help to detect PH earlier. METHODS A non-systematic literature review on the typical electrocardiographic patterns of PH was performed. RESULTS Characteristic signs of PH include right axis deviation, SIQIIITIII and SISIISIII patterns, P pulmonale, right bundle branch block, deep R waves in V1 and V2, deep S waves in V5 and V6, and right ventricular hypertrophy (R in V1 + S in V5, V6 > 1,05 mV). Repolarisation abnormalities such as ST segment depressions or T wave inversions in leads II, III, aVF, and V1 to V3 are common as well. Furthermore, a prolonged QT/QTc interval, an increased heart rate, or supraventricular tachyarrhythmias can be observed. Some parameters may even provide information about the patient's prognosis. CONCLUSION Not every PH patient shows electrocardiographic PH signs, especially in mild PH. Thus, the ECG is not useful to completely rule out PH, but provides important clues to PH when symptoms are present. The combination of typical ECG signs and the co-occurrence of electrocardiographic signs with clinical symptoms and elevated BNP levels are particularly suspicious. Diagnosing PH earlier could prevent further right heart strain and improve patient prognosis.
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7
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Bartnik A, Pepke-Zaba J, Hoole SP, White P, Garbi M, Coghlan JG, Taghavi F, Tsui S, Weir-McCall J. Right ventricular-pulmonary artery coupling in chronic thromboembolic pulmonary hypertension. Heart 2022; 109:898-904. [PMID: 36549680 DOI: 10.1136/heartjnl-2022-321770] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension occurs in a proportion of patients with prior acute pulmonary embolism and is characterised by breathlessness, persistently raised pulmonary pressures and right heart failure. Surgical pulmonary endarterectomy (PEA) offers significant prognostic and symptomatic benefits for patients with proximal disease distribution. For those with inoperable disease, management options include balloon pulmonary angioplasty (BPA) and medical therapy. Current clinical practice relies on the evaluation of pulmonary haemodynamics to assess disease severity, timing of and response to treatment. However, pulmonary haemodynamics correlate poorly with patient symptoms, which are influenced by right ventricular tolerance of the increased afterload. How best to manage symptomatic patients with chronic thromboembolic pulmonary disease (CTEPD) in the absence of pulmonary hypertension is not resolved.Right ventricular-pulmonary artery coupling (RV-PAC) describes the energy transfer within the whole cardiopulmonary unit. Thus, it can identify the earliest signs of decompensation even before pulmonary hypertension is overt. Invasive measurement of coupling using pressure volume loop technology is well established in research settings. The development of efficient and less invasive measurement methods has revived interest in coupling as a viable clinical tool. Significant improvement in RV-PAC has been demonstrated after both PEA and BPA. Further studies are required to understand its clinical utility and prognostic value, in particular, its potential to guide management in patients with CTEPD. Finally, given the reported differences in coupling between sexes in pulmonary arterial hypertension, further work is required to understand the applicability of proposed thresholds for decoupling in therapeutic decision making.
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Affiliation(s)
- Aleksandra Bartnik
- Radiology, Royal Papworth Hospital, Cambridge, UK .,University of Cambridge, Cambridge, UK.,Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Paul White
- Medical Physics and Clinical Engineering, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Medical Technology Research Centre, Anglia Ruskin University, Cambridge, UK
| | | | | | | | - Steven Tsui
- Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Jonathan Weir-McCall
- Radiology, Royal Papworth Hospital, Cambridge, UK.,University of Cambridge, Cambridge, UK
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Zhang Y, Li X, Jin Q, Luo Q, Zhao Q, Yang T, Zeng Q, Yan L, Duan A, Huang Z, Hu M, Xiong C, Zhao Z, Liu Z. The original and two new derivative versions of the COMPERA 2.0 risk assessment model: useful tools for guiding balloon pulmonary angioplasty. Respir Res 2022; 23:312. [PMCID: PMC9664665 DOI: 10.1186/s12931-022-02232-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background
The COMPERA 2.0 4-stratum (4-S) risk score has been demonstrated superior over the 3-stratum (3-S) one in patients with pulmonary arterial hypertension and medically managed patients with chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to determine the prognostic value of the original 4-S and 3-S COMPERA 2.0 risk score and two new derivative versions in CTEPH patients who underwent balloon pulmonary angioplasty (BPA).
Methods
We retrospectively enrolled 175 BPA-treated patients with CTEPH. We assessed the risk stratification before and after each BPA session of CTEPH patients by the original 4-S and 3-S COMPERA 2.0 risk score (by rounding decimal to the nearest integer) and two new proposed derivative versions: the modified version (by rounding decimal to the next integer) and a hybrid version that fuses the original and modified versions. The primary endpoint was clinical worsening events. The secondary outcomes were achieving low-risk profile and mean pulmonary arterial pressure (mPAP) < 30 mmHg at follow-up. We used the Kaplan–Meier curve analysis to assess the survival differences between stratified patients. The comparative model’s performance was evaluated in terms of discrimination by Harrell’s C-index.
Results
All versions of COMPERA 2.0 4-S model outperformed the 3-S one in discriminating the differences in echocardiographic and hemodynamic parameters and clinical worsening-free survival rates. The original and hybrid 4-S model could independently predict the primary and secondary endpoints, and the hybrid version seemed to perform better. The first BPA session could significantly improve risk profiles, and these changes were associated with the likelihood of experiencing clinical worsening events, achieving a low-risk profile and mPAP < 30 mmHg at follow-up. The number of BPA sessions required to achieve low risk/mPAP < 30 mmHg increased as the baseline risk score escalated.
Conclusions
The COMPERA 2.0 4-S model outperformed the 3-S one in BPA-treated patients with CTEPH. The 4-S model, especially its hybrid version, could be used to predict clinical outcome before the initiation of BPA and monitor treatment response.
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed, but potentially curable pulmonary vascular disease. The increased pulmonary vascular resistance in CTEPH is caused by unresolved proximal thrombus and secondary microvasculopathy in the pulmonary vasculature, leading to adaptive and maladaptive remodeling of the right ventricle (RV), eventual right heart failure, and death. Knowledge on the RV remodeling process in CTEPH is limited. The progression to RV failure in CTEPH is a markedly slower process. A detailed understanding of the pathophysiology and underlying mechanisms of RV remodeling may facilitate early diagnosis and the development of targeted therapy. While ultrasound, magnetic resonance imaging, right heart catheterization, and serum biomarkers have been used to assess cardiac function, the current treatment strategies reduce the afterload of the right heart, but are less effective in improving the maladaptive remodeling of the right heart. This review systematically summarizes the current knowledge on adaptive and maladaptive remodeling of the right heart in CTEPH from molecular mechanisms to clinical practice.
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Association of Electrocardiographic Signs of Right Ventricular Hypertrophy and Clot Localization in Chronic Thromboembolic Pulmonary Hypertension. J Clin Med 2022; 11:jcm11030625. [PMID: 35160075 PMCID: PMC8836771 DOI: 10.3390/jcm11030625] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 01/22/2022] [Accepted: 01/23/2022] [Indexed: 02/05/2023] Open
Abstract
The role of electrocardiography (ECG) in chronic thromboembolic pulmonary hypertension (CTEPH) diagnosis and prognosticating has not been yet established. We aimed to assess the relationships of the recommended ECG criteria of right ventricular hypertrophy (RVH) with clot localization in CTEPH patients. ECG patterns of RVH according to the American College of Cardiology Foundation were assessed in patients with newly diagnosed CTEPH. We enrolled 58 (45.3%) patients with proximal and 70 (54.7%) with distal CTEPH. Receiver-operating characteristics curves analysis indicated that the following ECG abnormalities predicted proximal CTEPH localization: RV1 > 6 mm—AUC 0.75 (CI: 0.66–0.84, p < 0.00001); SV6 > 3 mm—AUC 0.70 (CI: 0.60–0.79, p < 0.00001); SI > RI wave—AUC 0.67 (CI: 0.58–0.77, p = 0.0004); RV1:SV1 > 1.0—AUC 0.66 (CI: 0.56–0.76, p = 0.0009); RV1 peak > 0.035 s (QRS < 120 ms)—AUC 0.66 (CI: 0.56–0.75, p = 0.0016); RV1:SV1 > RV3(V4):SV3(V4)—AUC-0.65 (CI: 0.54–0.75, p = 0.0081); RaVR > 4 mm—AUC 0.62 (CI: 0.52–0.71, p = 0.002) and PII > 2.5 mm—AUC 0.62 (CI: 0.52–0.72, p = 0.00162). Pulmonary vascular resistance significantly correlated with amplitudes of RV1 (r = 0.34, p = 0.008), SV6 (r = 0.53, p = 0.000027) and PII (r = 0.44, p = 0.00007). In patients with CTEPH, only 8 out of 23 ECG RVH criteria were useful for differentiating between proximal and distal CTEPH localization and we found that RV1 and SV6 may contribute as potential discriminators.
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11
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Zhong C, Zhao H, Xie X, Qi Z, Li Y, Jia L, Zhang J, Lu Y. Protein Kinase C-Mediated Hyperphosphorylation and Lateralization of Connexin 43 Are Involved in Autoimmune Myocarditis-Induced Prolongation of QRS Complex. Front Physiol 2022; 13:815301. [PMID: 35418879 PMCID: PMC9000987 DOI: 10.3389/fphys.2022.815301] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/25/2022] [Indexed: 02/05/2023] Open
Abstract
Myocarditis is a serious and potentially life-threatening disease, which leads to cardiac dysfunction and sudden cardiac death. An increasing number of evidence suggests that myocarditis is also a malignant complication of coronavirus pneumonia, associated with heart failure and sudden cardiac death. Prolonged QRS complexes that are related to malignant arrhythmias caused by myocarditis significantly increase the risk of sudden cardiac death in patients. However, the molecular mechanisms are not fully known at present. In this study, we identify protein kinase C (PKC) as a new regulator of the QRS complex. In isolated hearts of normal rats, the PKC agonist, phorbol-12-myristate-13-acetate (PMA), induced prolongation of the QRS complex. Mechanistically, hyperphosphorylation and lateralization of connexin 43 (Cx43) by PKC induced depolymerization and internalization of Cx43 gap junction channels and prolongation of the QRS duration. Conversely, administration of the PKC inhibitor, Ro-32-0432, in experimental autoimmune myocarditis (EAM) rats after the most severe inflammation period still significantly rescued the stability of the Cx43 gap junction and alleviated prolongation of the QRS complex. Ro-32-0432 reduced phosphorylation and blocked translocation of Cx43 in EAM rat heart but did not regulate the mRNA expression level of ventricular ion channels and the other regulatory proteins, which indicates that the inhibition of PKC might have no protective effect on ion channels that generate ventricular action potential in EAM rats. These results suggest that the pharmacological inhibition of PKC ameliorates the prolongation of the QRS complex via suppression of Cx43 hyperphosphorylation, lateralization, and depolymerization of Cx43 gap junction channels in EAM rats, which provides a potential therapeutic strategy for myocarditis-induced arrhythmias.
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Affiliation(s)
- Chunlian Zhong
- School of Material and Chemical Engineering, Minjiang University, Fuzhou, China
- Fuzhou Institute of Oceanography, Fuzhou, China
| | - Huan Zhao
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, School of Life Sciences, National Institute of Diagnostics and Vaccine Development in Infectious Diseases, Xiamen University, Xiamen, China
| | - Xinwen Xie
- Liancheng County General Hospital, Longyan, China
| | - Zhi Qi
- Department of Basic Medical Sciences, Medical College of Xiamen University, Xiamen, China
| | - Yumei Li
- School of Basic Medicine, Gannan Medical University, Ganzhou, China
| | - Lee Jia
- School of Material and Chemical Engineering, Minjiang University, Fuzhou, China
- Fuzhou Institute of Oceanography, Fuzhou, China
- *Correspondence: Lee Jia, ,
| | - Jinwei Zhang
- Xiamen Key Laboratory of Cardiovascular Disease, Xiamen Cardiovascular Hospital Xiamen University, Xiamen, China
- Hatherly Laboratories, Medical School, College of Medicine and Health, Institute of Biomedical and Clinical Sciences, University of Exeter, Exeter, United Kingdom
- Jinwei Zhang,
| | - Yusheng Lu
- School of Material and Chemical Engineering, Minjiang University, Fuzhou, China
- Fuzhou Institute of Oceanography, Fuzhou, China
- Yusheng Lu, ,
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12
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Asano R, Ogo T, Morita Y, Kotoku A, Aoki T, Hirakawa K, Nakayama S, Ueda J, Tsuji A, Waddingham MT, Ohta Y, Fukuda T, Ohta-Ogo K, Ishibashi-Ueda H, Noguchi T, Yasuda S. Prognostic value of right ventricular native T1 mapping in pulmonary arterial hypertension. PLoS One 2021; 16:e0260456. [PMID: 34843578 PMCID: PMC8629295 DOI: 10.1371/journal.pone.0260456] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/09/2021] [Indexed: 11/18/2022] Open
Abstract
Background Right ventricular function is an important prognostic marker for pulmonary arterial hypertension. Native T1 mapping using cardiovascular magnetic resonance imaging can characterize the myocardium, but accumulating evidence indicates that T1 values of the septum or ventricular insertion points do not have predictive potential in pulmonary arterial hypertension. We aimed to elucidate whether native T1 values of the right ventricular free wall (RVT1) can predict poor outcomes in patients with pulmonary arterial hypertension. Methods This retrospective study included 30 patients with pulmonary arterial hypertension (median age, 45 years; mean pulmonary artery pressure, 41±13 mmHg) and 16 healthy controls (median age, 43 years) who underwent native T1 mapping. RVT1 was obtained from the inferior right ventricular free wall during end systole. Results Patients with pulmonary arterial hypertension had significantly higher native RVT1 than did controls (1384±74 vs. 1217±57 ms, p<0.001). Compared with T1 values of the septum or ventricular insertion points, RVT1 correlated better with the effective right ventricular elastance index (R = −0.53, p = 0.003), ventricular-arterial uncoupling (R = 0.46, p = 0.013), and serum brain natriuretic peptide levels (R = 0.65, p<0.001). Moreover, the baseline RVT1 was an accurate predictor of the reduced right ventricular ejection fraction at the 12-month follow-up (delta -3%). RVT1 was independently associated with composite events of death or hospitalization from any cause (hazard ratio = 1.02, p = 0.002). Conclusions RVT1 was predictive of right ventricular performance and outcomes in patients with pulmonary arterial hypertension. Thus, native T1 mapping in the right ventricular free wall may be an effective prognostic method for pulmonary arterial hypertension.
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Affiliation(s)
- Ryotaro Asano
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Osaka, Japan
- Department of Advanced Medical Research for Pulmonary Hypertension, National Cerebral and Cardiovascular Centre, Osaka, Japan
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takeshi Ogo
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Osaka, Japan
- Department of Advanced Medical Research for Pulmonary Hypertension, National Cerebral and Cardiovascular Centre, Osaka, Japan
- * E-mail:
| | - Yoshiaki Morita
- Department of Radiology, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Akiyuki Kotoku
- Department of Radiology, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Tatsuo Aoki
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Kyoko Hirakawa
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Sayuri Nakayama
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Jin Ueda
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Akihiro Tsuji
- Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Mark T. Waddingham
- Department of Advanced Medical Research for Pulmonary Hypertension, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Yasutoshi Ohta
- Department of Radiology, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Keiko Ohta-Ogo
- Department of Pathology, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | | | - Teruo Noguchi
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Satoshi Yasuda
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Osaka, Japan
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13
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Balloon pulmonary angioplasty reverse right ventricular remodelling and dysfunction in patients with inoperable chronic thromboembolic pulmonary hypertension: a systematic review and meta-analysis. Eur Radiol 2020; 31:3898-3908. [PMID: 33201287 DOI: 10.1007/s00330-020-07481-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/12/2020] [Accepted: 11/05/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Right ventricular (RV) function is considered the major determinant of prognosis in patients with chronic thromboembolic pulmonary hypertension (CTEPH). The aim of this meta-analysis was to evaluate RV remodelling and function following balloon pulmonary angioplasty (BPA) in patients with inoperable CTEPH or persistent/recurrent pulmonary hypertension (PH) after pulmonary endarterectomy (PEA). METHODS We reviewed all studies evaluating RV function by cardiac magnetic resonance (CMR) and/or echocardiography pre- and post-BPA from PubMed/Medline prior to 15 December 2019. Ten (299 patients) of the 29 studies retrieved met the inclusion criteria: 5 CMR and 5 echocardiography studies. The systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines. RESULTS Pooled data from CMR studies revealed BPA resulted in a significantly decreased RV end-diastolic volume index (weighted mean difference (WMD) - 28.33 ml/m2, p < 0.00001) and RV end-systolic volume index (WMD - 29.06 ml/m2, p < 0.00001) accompanied by an increased RV ejection fraction (RVEF, WMD 8.97%, p < 0.00001). Data from the echocardiography studies showed BPA resulted in decreased RV basal diameter (WMD - 0.37 cm, p = 0.0009) and an increase of RV fractional area change (WMD 5.97 %, p = 0.003), but improvements of tricuspid annular plane systolic excursion (TAPSE) and S' were not significant. CONCLUSIONS BPA improves RVEF and decreases RV volumes in patients with inoperable CTEPH or persistent/recurrent PH after PEA. KEY POINTS • Balloon pulmonary angioplasty improves RVEF and decreases RV volumes in patients with inoperable CTEPH or persistent/recurrent PH after PEA.
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14
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García Lledó A. The electrocardiogram in Pulmonary Hypertension: Scanning for an Iceberg. Arch Bronconeumol 2020; 57:319-320. [PMID: 32839056 DOI: 10.1016/j.arbres.2020.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Alberto García Lledó
- Servicio de Cardiología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España; Departamento de Medicina, Universidad de Alcalá, Alcalá de Henares, Madrid, España.
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15
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Piłka M, Darocha S, Banaszkiewicz M, Wieteska-Miłek M, Mańczak M, Mańczak R, Kędzierski P, Florczyk M, Dobosiewicz A, Torbicki A, Kurzyna M. Assessment of electrocardiographic markers of acute and long-term hemodynamic improvement in patients with pulmonary hypertension. Ann Noninvasive Electrocardiol 2020; 25:e12758. [PMID: 32335975 PMCID: PMC7507443 DOI: 10.1111/anec.12758] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/22/2020] [Accepted: 03/08/2020] [Indexed: 01/23/2023] Open
Abstract
Background The remodeling of the right heart in patients with chronic pulmonary hypertension (cPH) is associated with the appearance of electrocardiographic (ECG) abnormalities. We investigated the resolution of ECG markers of right ventricular hypertrophy (RVH) caused by acute and long‐term hemodynamic improvement. Methods Twenty‐nine (29) patients with chronic thromboembolic pulmonary hypertension (CTEPH) and seven patients with pulmonary arterial hypertension (PAH) were included in the analysis. Patients with CTEPH achieved a significant long‐term hemodynamic improvement following the treatment with balloon pulmonary angioplasty (BPA); all the patients with PAH reported significant acute hemodynamic relief after a single inhalation of iloprost, fulfilling the criteria of responder. Standard 12‐lead ECG was performed before and after intervention. Results The interval between baseline and control ECG in CTEPH and PAH groups was 28 (IQR: 17–36) months and 15 min (IQR: 11–17), respectively. Despite similar hemodynamic improvement in both groups, only the CTEPH group presented significant changes in most analyzed ECG parameters: T‐wave axis (p = .002), QRS‐wave axis (p = .012), P‐wave amplitude (p < .001) and duration in II (p = .049), R‐wave amplitude in V1 (p = .017), R:S ratio in V1 (p = .046), S‐wave amplitude in V5 (p = .004), R‐wave amplitude in V5 (p = .044), R:S ratio in V5 (p = .004), S‐wave amplitude in V6 (p = .026), R‐wave amplitude in V6 (p = .01), and R‐wave amplitude in aVR (p = .031). In patients with PAH, significant differences were found only for P wave in II (duration: p = .035; amplitude: p = .043) and QRS axis (p = .018). Conclusions The effective treatment of cPH ensures improvement in ECG parameters of RVH, but it requires extended time.
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Affiliation(s)
- Michał Piłka
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Szymon Darocha
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Marta Banaszkiewicz
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Maria Wieteska-Miłek
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Małgorzata Mańczak
- Department of Gerontology, Public Health and Didactics, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Rafał Mańczak
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Piotr Kędzierski
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Michał Florczyk
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Anna Dobosiewicz
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
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16
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QRS change in heart failure: When is the right time for cardiac resynchronization therapy? Int J Cardiol 2019; 296:87-88. [PMID: 31474411 DOI: 10.1016/j.ijcard.2019.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/09/2019] [Indexed: 11/23/2022]
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