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Baratto C, Caravita S, Soranna D, Dewachter C, Bondue A, Zambon A, Badano LP, Parati G, Vachiéry J. An updated meta-analysis of hemodynamics markers of prognosis in patients with pulmonary hypertension due to left heart disease. Pulm Circ 2022; 12:e12145. [PMID: 36568693 PMCID: PMC9768568 DOI: 10.1002/pul2.12145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/20/2022] [Accepted: 07/14/2022] [Indexed: 12/27/2022] Open
Abstract
Pulmonary hypertension (PH) is associated with a poor prognosis in left heart disease (LHD). We sought to provide an updated analysis on the association of hemodynamic variables, such as pulmonary vascular resistance (PVR), pulmonary artery compliance (PAC), and diastolic pressure gradient (DPG), with prognosis in PH-LHD, through a systematic literature review. Sixteen articles were identified, including 9600 patients with LHD, heterogeneous in terms of age, sex, and etiology of cardiac disease. In this large population, PVR (hazard ratio [HR], 1.07; 95% confidence interval [CI]: 1.05-1.0), DPG (HR, 1.02; 95% CI: 1.01-1.02) and PAC (HR, 0.76; 95% CI: 0.69-0.84) were associated with an increased risk of adverse outcome, albeit with a less solid performance of DPG. Similar results were found when hemodynamic variables were analyzed according to the thresholds commonly applied in clinical practice, or subdividing cohorts according to the underlying LHD. Furthermore, cumulative metanalysis indicated that these results are consistently stable since 2018. Thus, PVR, DPG and PAC have an established prognostic value in PH-LHD. These results are consistent through the years and unlikely to change with further studies.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCSOspedale San LucaMilanoItaly
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCSOspedale San LucaMilanoItaly,Department of Management, Information and Production EngineeringUniversity of BergamoDalmine (BG)Italy
| | - Davide Soranna
- IRCCS Istituto Auxologico ItalianoBiostatistics UnitMilanItaly
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de BruxellesHôpital Académique ErasmeBruxellesBelgium
| | - Antoine Bondue
- Department of Cardiology, Cliniques Universitaires de BruxellesHôpital Académique ErasmeBruxellesBelgium
| | - Antonella Zambon
- IRCCS Istituto Auxologico ItalianoBiostatistics UnitMilanItaly,Department of Statistic and Quantitative MethodsUniversity of Milano‐BicoccaMilanItaly
| | - Luigi P. Badano
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCSOspedale San LucaMilanoItaly,Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanoItaly
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCSOspedale San LucaMilanoItaly,Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanoItaly
| | - Jean‐Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de BruxellesHôpital Académique ErasmeBruxellesBelgium
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2
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Boxhammer E, Gharibeh SX, Wernly B, Kelm M, Franz M, Kretzschmar D, Hoppe UC, Lauten A, Lichtenauer M. Conundrum of Classifying Subtypes of Pulmonary Hypertension-Introducing a Novel Approach to Classify "Borderline" Patients in a Population with Severe Aortic Stenosis Undergoing TAVI. J Cardiovasc Dev Dis 2022; 9:jcdd9090294. [PMID: 36135439 PMCID: PMC9505198 DOI: 10.3390/jcdd9090294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/23/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Transcatheter aortic valve implantation (TAVI) is an established therapeutic option in patients with severe aortic valve stenosis (AS) and a high surgical risk profile. Pulmonary hypertension (PH)—often co-existing with severe AS—is associated with a limited factor for prognosis and survival. The purpose of this study was to evaluate the prevalence of PH in patients undergoing TAVI, classify these patients based on right heart catheter (RHC) measurements in different PH subtypes, and analyze prognostic values on survival after TAVI. Methods: 284 patients with severe AS underwent an RHC examination for hemodynamic assessment prior to TAVI and were categorized into subtypes of PH according to the 2015 European Society of Cardiology (ESC) guidelines. TAVI patients were followed-up with for one year with regard to 30-days and 1-year mortality as primary endpoints. Results: 74 of 284 participants showed a diastolic pressure gradient (DPG) < 7 mmHg and a pulmonary vascular resistance (PVR) > 3 Wood units (WU) and could not be formally allocated to either isolated post-capillary PH (ipc-PH) or combined pre- and post-capillary PH (cpc-PH). Therefore, a new subgroup called “borderline post-capillary PH” (borderlinepc-PH) was introduced. Compared with TAVI patients with pre-capillary PH (prec-PH), ipc-PH patients suffering from borderlinepc-PH (HR 7.114; 95% CI 2.015−25.119; p = 0.002) or cpc-PH (HR 56.459; 95% CI 7.738−411.924; p < 0.001) showed a significantly increased 1-year mortality. Conclusions: Postcapillary PH was expanded to include the so-called “borderlinepc-PH” variant in addition to the ipc-PH and cpc-PH subtypes. The one-year survival after TAVI was significantly different between the subgroups, with the worst prognosis for borderlinepc-PH and cpc-PH.
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Affiliation(s)
- Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Sarah X. Gharibeh
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Bernhard Wernly
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, 5110 Oberndorf, Austria
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Düsseldorf, 40225 Düsseldorf, Germany
| | - Marcus Franz
- Universitätsherzzentrum Thüringen, Clinic of Internal Medicine I, Departement of Cardiology, Friedrich Schiller University, 07737 Jena, Germany
| | - Daniel Kretzschmar
- Universitätsherzzentrum Thüringen, Clinic of Internal Medicine I, Departement of Cardiology, Friedrich Schiller University, 07737 Jena, Germany
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Alexander Lauten
- Department of General and Interventional Cardiology and Rhythmology, Helios Clinic, 99084 Erfurt, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Berlin, 10115 Berlin, Germany
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
- Correspondence:
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3
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Boxhammer E, Mirna M, Bäz L, Alushi B, Franz M, Kretzschmar D, Hoppe UC, Lauten A, Lichtenauer M. Comparison of PCWP and LVEDP Measurements in Patients with Severe Aortic Stenosis Undergoing TAVI-Same Same but Different? J Clin Med 2022; 11:jcm11112978. [PMID: 35683367 PMCID: PMC9181042 DOI: 10.3390/jcm11112978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/18/2022] [Accepted: 05/23/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pulmonary capillary wedge pressure (PCWP) and left ventricular end-diastolic pressure (LVEDP) are often used as equivalents for determination of pulmonary hypertension (PH). PH is a comorbidity in patients with severe aortic valve stenosis (AS) and associated with limited prognosis. The aim of the study was to examine the role of differentiated classification basis of PCWP and LVEDP in patients planning for transcatheter aortic valve implantation (TAVI). METHODS 284 patients with severe AS completed a combined left (LHC) and right heart catheterization (RHC) as part of a TAVI planning procedure. Patients were categorized twice into subtypes of PH according to 2015 European Society of Cardiology (ESC) guidelines-on the one hand with PCWP and on the other hand with LVEDP as classification basis. PCWP-LVEDP relationships were figured out using Kaplan-Meier curves, linear regressions and Bland-Altman analysis. RESULTS Regarding 1-year mortality, Kaplan-Meier analyses showed similar curves in spite of different classification bases of PH subtypes according to PCWP or LVEDP with exception of pre-capillary PH subtype. PCWP-LVEDP association in the overall cohort was barely present (R = 0.210, R2 = 0.044). When focusing analysis on PH patients only a slightly increased linear regression was noted compared to the overall cohort (R = 0.220, R2 = 0.048). The strongest regression was observed in patients with creatinine ≥ 132 µmol/L (R = 0.357, R2 = 0.127) and in patients with mitral regurgitation ≥ II° (R = 0.326, R2 = 0.106). CONCLUSIONS In patients with severe AS, there is a weak association between hemodynamic parameters measured by LHC and RHC. RHC measurements alone are not suitable for risk stratification with respect to one-year mortality. If analysis of hemodynamic parameters is necessary in patients with severe AS scheduled for TAVI, measurement results of LHC and RHC should be combined and LVEDP could serve as a helpful indicator for risk assessment.
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Affiliation(s)
- Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (M.M.); (U.C.H.)
| | - Moritz Mirna
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (M.M.); (U.C.H.)
| | - Laura Bäz
- Universitäts-Herzzentrum Thüringen, Clinic of Internal Medicine I, Department of Cardiology, Friedrich Schiller University, 07743 Jena, Germany; (L.B.); (M.F.); (D.K.)
| | - Brunilda Alushi
- Department of General and Interventional Cardiology and Rhythmology, Helios Hospital Erfurt, 99089 Erfurt, Germany; (B.A.); (A.L.)
| | - Marcus Franz
- Universitäts-Herzzentrum Thüringen, Clinic of Internal Medicine I, Department of Cardiology, Friedrich Schiller University, 07743 Jena, Germany; (L.B.); (M.F.); (D.K.)
| | - Daniel Kretzschmar
- Universitäts-Herzzentrum Thüringen, Clinic of Internal Medicine I, Department of Cardiology, Friedrich Schiller University, 07743 Jena, Germany; (L.B.); (M.F.); (D.K.)
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (M.M.); (U.C.H.)
| | - Alexander Lauten
- Department of General and Interventional Cardiology and Rhythmology, Helios Hospital Erfurt, 99089 Erfurt, Germany; (B.A.); (A.L.)
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Berlin, 10785 Berlin, Germany
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (M.M.); (U.C.H.)
- Correspondence:
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Zhong XJ, Jiang R, Yang L, Yuan P, Gong SG, Zhao QH, Luo CJ, Qiu HL, Li HT, Zhang R, He J, Wang L, Tang J, Liu JM. Peak oxygen uptake is a strong prognostic predictor for pulmonary hypertension due to left heart disease. BMC Cardiovasc Disord 2022; 22:137. [PMID: 35361128 PMCID: PMC8974096 DOI: 10.1186/s12872-022-02574-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 03/11/2022] [Indexed: 11/18/2022] Open
Abstract
Background Pulmonary hypertension in left heart disease (PH-LHD), which includes combined post- and precapillary PH (Cpc-PH) and isolated postcapillary PH (Ipc-PH), differs significantly in prognosis. We aimed to assess whether cardiopulmonary exercise testing (CPET) predicts the long-term survival of patients with PH-LHD. Methods A single-center observational cohort enrolled 89 patients with PH-LHD who had undergone right heart catherization and CPET (mean pulmonary arterial pressure > 20 mm Hg and pulmonary artery wedge pressure ≥ 15 mm Hg) between 2013 and 2021. A receiver operating characteristic curve was plotted to determine the cutoff value of all-cause death. Survival was estimated using the Kaplan–Meier method and analyzed using the log-rank test. The Cox proportional hazards model was performed to determine the association between CPET and all-cause death. Results Seventeen patients died within a mean of 2.2 ± 1.3 years. Compared with survivors, nonsurvivors displayed a significantly worse 6-min walk distance, workload, exercise time and peak oxygen consumption (VO2)/kg with a trend of a lower oxygen uptake efficiency slope (OUES) adjusted by Bonferroni’s correction. Multivariate Cox regression revealed that the peak VO2/kg was significantly associated with all-cause death after adjusting for Cpc-PH/Ipc-PH. Compared with Cpc-PH patients with a peak VO2/kg ≥ 10.7 ml kg−1 min−1, Ipc-PH patients with a peak VO2/kg < 10.7 ml kg−1 min−1 had a worse survival (P < 0.001). Conclusions The peak VO2/kg is independently associated with all-cause death in patients with PH-LHD. The peak VO2/kg can also be analyzed together with Cpc-PH/Ipc-PH to better indicate the prognosis of patients with PH-LHD. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02574-0.
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Affiliation(s)
- Xiu-Jun Zhong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China.,Department of Respiratory Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, China
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China
| | - Lu Yang
- Department of Cardiology, Second Affiliated Hospital of Nanchang University, 1 Minde Road, Nanchang, 330006, China
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China
| | - Su-Gang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China
| | - Ci-Jun Luo
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China
| | - Hong-Ling Qiu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China
| | - Hui-Ting Li
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China
| | - Rui Zhang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China
| | - Jing He
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China.
| | - Jie Tang
- Department of Respiratory Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, China.
| | - Jin-Ming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China.
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5
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Liu S, Yan Y. Animal models of pulmonary hypertension due to left heart disease. Animal Model Exp Med 2022; 5:197-206. [PMID: 35234367 PMCID: PMC9240728 DOI: 10.1002/ame2.12214] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/13/2022] [Accepted: 01/23/2022] [Indexed: 01/02/2023] Open
Abstract
Pulmonary hypertension due to left heart disease (PH‐LHD) is regarded as the most prevalent form of pulmonary hypertension (PH). Indeed, PH is an independent risk factor and predicts adverse prognosis for patients with left heart disease (LHD). Clinically, there are no drugs or treatments that directly address PH‐LHD, and treatment of LHD alone will not also ameliorate PH. To target the underlying physiopathological alterations of PH‐LHD and to develop novel therapeutic approaches for this population, animal models that simulate the pathophysiology of PH‐LHD are required. There are several available models for PH‐LHD that have been successfully employed in rodents or large animals by artificially provoking an elevated pressure load on the left heart, which by transduction elicits an escalated pressure in pulmonary artery. In addition, metabolic derangement combined with aortic banding or vascular endothelial growth factor receptor antagonist is also currently applied to reproduce the phenotype of PH‐LHD. As of today, none of the animal models exactly recapitulates the condition of patients with PH‐LHD. Nevertheless, the selection of an appropriate animal model is essential in basic and translational studies of PH‐LHD. Therefore, this review will summarize the characteristics of each PH‐LHD animal model and discuss the advantages and limitations of the different models.
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Affiliation(s)
- Shao‐Fei Liu
- Charité—Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
- DZHK (German Centre for Cardiovascular Research) Partner Site Berlin Berlin Germany
| | - Yi Yan
- Institute for Cardiovascular Prevention (IPEK) Ludwig‐Maximilians‐University Munich Munich Germany
- DZHK (German Centre for Cardiovascular Research) Partner Site Munich Heart Alliance Munich Germany
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6
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Ibe T, Wada H, Sakakura K, Ugata Y, Maki H, Yamamoto K, Seguchi M, Taniguchi Y, Jinnouchi H, Momomura SI, Fujita H. Combined pre- and post-capillary pulmonary hypertension: The clinical implications for patients with heart failure. PLoS One 2021; 16:e0247987. [PMID: 33651852 PMCID: PMC7924774 DOI: 10.1371/journal.pone.0247987] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/17/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The prognostic implications of combined pre- and post-capillary pulmonary hypertension (Cpc-PH) in patients with pulmonary hypertension due to left heart disease (PH-LHD) remain controversial. The aim of this retrospective study was to evaluate the new PH-LHD criteria, recommended by the 6th World Symposium on Pulmonary Hypertension and to determine the prognostic value of Cpc-PH. METHODS A total of 701 patients with symptomatic heart failure who had undergone right-heart catheterization were divided into the following four groups: (i) Isolated post-capillary PH (Ipc-PH) group; mean pulmonary artery pressure (mPAP) >20 mmHg, pulmonary artery wedge pressure (PAWP) >15 mmHg, and pulmonary vascular resistance (PVR) <3 Wood units (WU) (ii) Cpc-PH group; mPAP >20 mmHg, PAWP >15 mmHg, and PVR ≥3 WU (iii) borderline-PH group; mPAP >20 mmHg and PAWP ≤15 mmHg (iv) non-PH group; mPAP ≤20 mmHg. Multivariate Cox hazard analysis was used to investigate whether Cpc-PH was associated with cardiac outcomes. RESULTS The study subjects were allocated into the Ipc-PH (n = 268), Cpc-PH (n = 54), borderline-PH (n = 112), or non-PH (n = 267) groups. The Cpc-PH group was associated significantly with adverse cardiac events even after adjustment for clinically relevant confounding factors for heart failure prognosis (vs. non-PH group: HR 2.98 [95% CI 1.81-4.90], P <0.001; vs. Ipc-PH group: HR: 1.92 [95% CI 1.19-3.08], P = 0.007). CONCLUSIONS The new definitions of PH-LHD stratified patients into 4 categories. Long-term clinical outcomes were significantly different between the four categories, with Cpc-PH having the worst cardiac outcomes.
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Affiliation(s)
- Tatsuro Ibe
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroshi Wada
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
- * E-mail:
| | - Kenichi Sakakura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yusuke Ugata
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hisataka Maki
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kei Yamamoto
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Masaru Seguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yousuke Taniguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroyuki Jinnouchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shin-ichi Momomura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hideo Fujita
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Lee F, Mielniczuk LM. Pulmonary Hypertension Due to Left Heart Disease-A Practical Approach to Diagnosis and Management. Can J Cardiol 2020; 37:572-584. [PMID: 33217522 DOI: 10.1016/j.cjca.2020.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/01/2020] [Accepted: 11/10/2020] [Indexed: 01/07/2023] Open
Abstract
Pulmonary hypertension (PH) due to left heart disease (LHD) is a frequent complication of heart failure (HF) and is associated with exercise intolerance, poor quality of life, increased risk of hospitalisations, and reduced overall survival. Since the recent Sixth World Symposium on Pulmonary Hypertension in 2018, there have been significant changes in the hemodynamic definitions and clinical classification of PH-LHD. PH-LHD can be subdivided into (1) isolated postcapillary PH (IpcPH) and (2) combined precapillary and postcapillary PH (CpcPH). This categorisation of PH-LHD is important because CpcPH shares certain pathophysiologic, clinical, and hemodynamic characteristics with pulmonary arterial hypertension and is associated with worse outcomes compared with IpcPH. A systematic approach using clinical history and noninvasive investigations is required in the diagnosis of PH-LHD. Right heart catheterisation with and without provocative testing is performed in expert centres and is indicated in selected individuals. Although the definition of IpcPH and CpcPH is based on measurements made with right heart catheterisation, distinguishing between these two entities is not always necessary. Despite strong evidence for medical therapy in patients with pulmonary arterial hypertension, those options have limited benefit in PH-LHD. Expert PH centres in Canada have been established to provide ongoing care for the more complex patient subgroups.
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Affiliation(s)
- Felicity Lee
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Lisa M Mielniczuk
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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8
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Manouras A, Lund LH, Gellér L, Nagy AI, Johnson J. Critical appraisal of the instantaneous end-diastolic pulmonary arterial wedge pressures. ESC Heart Fail 2020; 7:4247-4255. [PMID: 33021347 PMCID: PMC7754752 DOI: 10.1002/ehf2.13057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 11/10/2022] Open
Abstract
Aims A substantial shift in the field of pulmonary hypertension (PH) is ongoing, as the previous practice of mean pulmonary arterial wedge pressure (PAWPM) is no longer supported. Instead, aiming for a better estimate of end‐diastolic pressures (EDP), instantaneous PAWP at mid‐A‐wave (PAWPmid‐A) or, in the absence of an A‐wave, at 130–160 ms following QRS onset has recently been recommended. Electrocardiogram‐gated PAWP (PAWPQRS) has also been proposed. The quantitative differences as well as the diagnostic and prognostic utility of these novel PAWP measurements have not been evaluated. We set out to address these issues. Methods and results Pressure tracings of 141 patients with PH due to left heart disease (PH‐LHD) and 43 with primary pulmonary arterial hypertension (PAH) were analysed. PAWP was measured as follows: (i) mean pressure (PAWPM); (ii) per the latest consensus approach [PAWPmid‐A, or in atrial fibrillation 130, 140, 150, and 160 ms following QRS onset (PAWP130–160)]; (iii) at QRS onset (PAWPQRS); and (iv) Z‐point (PAWPZ). For each PAWP, the corresponding pulmonary vascular resistance (PVR) and diastolic pressure gradient were calculated. The cohort comprised 45% female. Mean age was 66 ± 15. PAWPmid‐A was in good agreement with PAWPZ (17.3 [14.5 to 21.2] vs. 17.6 [14.2 to 21.6] mmHg, P = 0.63), whereas PAWPQRS provided significantly lower values (15.3 [12.5 to 19.2] mmHg, P < 0.001). In atrial fibrillation, PAWP130 and PAWPQRS yielded the optimal temporal and quantitative analyses of EDPs. The ability to differentiate PAH from PH‐LHD was similar for the various PAWP measurements [PAWPM: area under the curve (AUC) 0.98, confidence interval (CI) 0.96–0.99; PAWPmid‐A/130: AUC 0.94, CI 0.91–0.98; PAWPQRS: AUC 0.96, CI 0.94–0.99, P < 0.001 for all]. PVR based on instantaneous PAWP measurements failed to provide superior prognostic information in PH‐LHD as compared with conventional PVR. Conclusions Although instantaneous PAWP measurement might better represent EDP, they nevertheless fail to yield incremental diagnostic or prognostic information in PH‐LHD as compared with conventional measurements.
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Affiliation(s)
- Aristomenis Manouras
- Institution for Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Theme of Heart and Vessels, Karolinska University Hospital, Stockholm, Sweden
| | - Lars H Lund
- Institution for Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Theme of Heart and Vessels, Karolinska University Hospital, Stockholm, Sweden
| | - László Gellér
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Anikó Ilona Nagy
- Institution for Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Jonas Johnson
- Centre for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
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9
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Raitière O, Berthelot E, Fauvel C, Guignant P, Si Belkacem N, Sitbon O, Bauer F. The dangerous and contradictory prognostic significance of PVR<3WU when TAPSE<16mm in postcapillary pulmonary hypertension. ESC Heart Fail 2020; 7:2398-2405. [PMID: 32705818 PMCID: PMC7524100 DOI: 10.1002/ehf2.12785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/26/2020] [Accepted: 05/04/2020] [Indexed: 11/10/2022] Open
Abstract
Aims In 2019, pulmonary vascular resistance (PVR) < 3WU was adopted to stratify patients at low risk in pulmonary hypertension due to left heart disease (PH‐LHD) as well those with isolated PH‐LHD. We sought to evaluate whether supervised machine learning with decision tree analysis, which provides more information than Cox Proportional analysis by forming a hierarchy of multiple covariates, confirms this risk stratification. Methods and results Two hundred two consecutive patients (mean age: 69 ± 11 years, female: 42%) with mean pulmonary artery pressure ≥ 20 mmHg and wedge pressure > 15 mmHg were recruited. Transpulmonary pressure gradient ⩾̸ 12 mmHg, PVR ⩾̸ 3WU, diastolic pressure gradient ⩾̸ 7 mmHg, pulmonary arterial capacitance < 1.1 mL/mmHg, tricuspid annular plane systolic excursion (TAPSE) < 16 mm, peak systolic tissue Doppler velocity < 10 cm/s, right ventricular end‐diastolic area ⩾̸ 25 cm2 were the seven categorical values entered into the model due to their prognostic significance in PH. We used the chi‐squared automatic interaction detection method to predict mortality. Each node and branch were compared using survival analysis at 6‐year follow‐up. Mean pulmonary artery pressure, wedge pressure, cardiac index, and PVR were 40.3 ± 10.0 mmHg, 22.3 ± 7.1 mmHg, 2.9 ± 0.8 L/min/m2, and 3.6 ± 2.1WU, respectively. Among the seven dichotomous, TAPSE was first selected following by PVR. Compared with patients with PVR < 3WU and TAPSE ⩾̸ 16 mm, patients with PVR ⩾̸ 3WU and TAPSE ⩾̸ 16 mm, or patients with PVR ⩾̸ 3WU and TAPSE<16 mm had significantly increased mortality, HR = 3.0, 95% CI = [1.4–6.4], P = 0.006 and HR = 3.3, 95% CI = [1.6–6.9], P = 0.002, respectively, while patients with PVR < 3WU and TAPSE < 16 mm exhibited the worst prognosis, HR = 7.2, 95% CI = [3.3–15.9], P = 0.0001. Conclusions Used for solving regression and classification problems, decision tree analysis confirms that PVR and TAPSE have to be analysed together in PH‐LHD and revealed the dangerous and contradictory prognostic significance of PVR < 3WU when TAPSE<16 mm.
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Affiliation(s)
- Olivier Raitière
- Department of Cardiac Surgery, Advanced Heart Failure Clinic and Pulmonary Hypertension Referral Center 27/76, Rouen University Hospital, Rouen, F76000, France.,Department of Cardiac Surgery, Normandie Univ, UNIROUEN, INSERM U1096, Rouen University Hospital, Rouen, F76000, France
| | - Emmanuelle Berthelot
- Department of Cardiology, APHP, Le Kremlin-Bicêtre University Hospital, Paris, 94276, France
| | - Charles Fauvel
- Department of Cardiac Surgery, Advanced Heart Failure Clinic and Pulmonary Hypertension Referral Center 27/76, Rouen University Hospital, Rouen, F76000, France
| | - Pierre Guignant
- Department of Cardiac Surgery, Advanced Heart Failure Clinic and Pulmonary Hypertension Referral Center 27/76, Rouen University Hospital, Rouen, F76000, France
| | - Nassima Si Belkacem
- Department of Cardiac Surgery, Advanced Heart Failure Clinic and Pulmonary Hypertension Referral Center 27/76, Rouen University Hospital, Rouen, F76000, France
| | - Olivier Sitbon
- Department of Cardiology, APHP, Le Kremlin-Bicêtre University Hospital, Paris, 94276, France.,INSERM UMR_S999, Université Paris-Sud, Hôpital Bicêtre, Le Kremlin-Bicêtre, 94270, France
| | - Fabrice Bauer
- Department of Cardiac Surgery, Advanced Heart Failure Clinic and Pulmonary Hypertension Referral Center 27/76, Rouen University Hospital, Rouen, F76000, France.,Department of Cardiac Surgery, Normandie Univ, UNIROUEN, INSERM U1096, Rouen University Hospital, Rouen, F76000, France
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Zhong XJ, Tang J, Zhao QH, Gong SG, Jiang R, Liu JM, Wang L. Can the diastolic pulmonary pressure gradient provide cardiopulmonary capacity information in patients with pulmonary hypertension and left heart disease? Int J Cardiol 2020; 305:138. [PMID: 32151339 DOI: 10.1016/j.ijcard.2019.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 12/10/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Xiu-Jun Zhong
- Department of Respiratory Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China; Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
| | - Jie Tang
- Department of Respiratory Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
| | - Su-Gang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China
| | - Jin-Ming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China.
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433, China.
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Aronson D. Cardiopulmonary testing in pulmonary hypertension due to left heart disease. Int J Cardiol 2020; 305:137. [DOI: 10.1016/j.ijcard.2020.02.020] [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: 01/14/2020] [Accepted: 02/07/2020] [Indexed: 11/29/2022]
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12
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Right Heart Catheterization-Background, Physiological Basics, and Clinical Implications. J Clin Med 2019; 8:jcm8091331. [PMID: 31466390 PMCID: PMC6780851 DOI: 10.3390/jcm8091331] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/17/2019] [Accepted: 08/25/2019] [Indexed: 11/17/2022] Open
Abstract
The idea of right heart catheterization (RHC) grew in the milieu of modern thinking about the cardiovascular system, influenced by the experiments of William Harvey, which were inspired by the treatises of Greek philosophers like Aristotle and Gallen, who made significant contributions to the subject. RHC was first discovered in the eighteenth century by William Hale and was subsequently systematically improved by outstanding experiments in the field of physiology, led by Cournand and Dickinson Richards, which finally resulted in the implementation of pulmonary artery catheters (PAC) into clinical practice by Jeremy Swan and William Ganz in the early 1970s. Despite its premature euphoric reception, some further analysis seemed not to share the early enthusiasm as far as the safety and effectiveness issues were concerned. Nonetheless, RHC kept its significant role in the diagnosis, prognostic evaluation, and decision-making of pulmonary hypertension and heart failure patients. Its role in the treatment of end-stage heart failure seems not to be fully understood, although it is promising. PAC-guided optimization of the treatment of patients with ventricular assist devices and its beneficial introduction into clinical practice remains a challenge for the near future.
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