1
|
Luna-Lopez R, Segura de la Cal T, Sarnago Cebada F, Martin de Miguel I, Hinojosa W, Cruz-Utrilla A, Velazquez MT, Delgado JF, Mendoza A, Arribas Ynsaurriaga F, Escribano-Subías P. Triple vasodilator therapy in pulmonary arterial hypertension associated with congenital heart disease. Heart 2024; 110:346-352. [PMID: 37903556 DOI: 10.1136/heartjnl-2023-323015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/03/2023] [Indexed: 11/01/2023] Open
Abstract
OBJECTIVE This study assessed the long-term effects of triple therapy with prostanoids on patients with pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD), as there is limited information on the safety and efficacy of this treatment approach. METHODS A retrospective cohort study was conducted on patients with PAH-CHD who were actively followed up at our centre. All patients were already receiving dual combination therapy at maximum doses. Clinical characteristics, including functional class (FC), 6-minute walking test distance (6MWTD) and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, were documented before initiating triple therapy and annually for a 2-year follow-up period. RESULTS A total of 60 patients were included in the study, with a median age of 41 years and 68% being women. Of these, 32 had Eisenmenger syndrome, 9 had coincidental shunts, 18 had postoperative PAH and 1 had a significant left-to-right shunt. After 1 year of triple combination initiation, a significant improvement in 6MWTD was observed (406 vs 450; p=0.0027), which was maintained at the 2-year follow-up. FC improved in 79% of patients at 1 year and remained stable in 76% at 2 years. NT-proBNP levels decreased significantly by 2 years, with an average reduction of 199 ng/L. Side effects were experienced by 33.3% of patients but were mostly mild and manageable. Subgroup analysis showed greater benefits in patients without Eisenmenger syndrome and those with pre-tricuspid defects. CONCLUSIONS Triple therapy with prostanoids is safe and effective for patients with PAH-CHD, improving FC, 6MWTD and NT-proBNP levels over 2 years. The treatment is particularly beneficial for patients with pre-tricuspid defects and non-Eisenmenger PAH-CHD.
Collapse
Affiliation(s)
- Raquel Luna-Lopez
- Adult Congenital Heart Disease Unit, Department of Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas12), Madrid, Spain
- Pulmonary Hyertension Unit, Department of Cardiology. Hospital Universitario 12 de Octubre, Hospital Universitario 12 de Octubre, Madrid, Spain
- Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Teresa Segura de la Cal
- Adult Congenital Heart Disease Unit, Department of Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas12), Madrid, Spain
- Pulmonary Hyertension Unit, Department of Cardiology. Hospital Universitario 12 de Octubre, Hospital Universitario 12 de Octubre, Madrid, Spain
- Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Fernando Sarnago Cebada
- Adult Congenital Heart Disease Unit, Department of Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas12), Madrid, Spain
- Pulmonary Hyertension Unit, Department of Cardiology. Hospital Universitario 12 de Octubre, Hospital Universitario 12 de Octubre, Madrid, Spain
- Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBERCV, Madrid, Spain
| | - Irene Martin de Miguel
- Adult Congenital Heart Disease Unit, Department of Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas12), Madrid, Spain
- Pulmonary Hyertension Unit, Department of Cardiology. Hospital Universitario 12 de Octubre, Hospital Universitario 12 de Octubre, Madrid, Spain
- Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Williams Hinojosa
- Pulmonary Hyertension Unit, Department of Cardiology. Hospital Universitario 12 de Octubre, Hospital Universitario 12 de Octubre, Madrid, Spain
- Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Alejandro Cruz-Utrilla
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas12), Madrid, Spain
- Pulmonary Hyertension Unit, Department of Cardiology. Hospital Universitario 12 de Octubre, Hospital Universitario 12 de Octubre, Madrid, Spain
- Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Maria Teresa Velazquez
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas12), Madrid, Spain
- Pulmonary Hyertension Unit, Department of Cardiology. Hospital Universitario 12 de Octubre, Hospital Universitario 12 de Octubre, Madrid, Spain
- Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBERCV, Madrid, Spain
| | - Juan F Delgado
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas12), Madrid, Spain
- Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBERCV, Madrid, Spain
| | - Alberto Mendoza
- Adult Congenital Heart Disease Unit, Department of Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Fernando Arribas Ynsaurriaga
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas12), Madrid, Spain
- Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBERCV, Madrid, Spain
| | - Pilar Escribano-Subías
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas12), Madrid, Spain
- Pulmonary Hyertension Unit, Department of Cardiology. Hospital Universitario 12 de Octubre, Hospital Universitario 12 de Octubre, Madrid, Spain
- Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBERCV, Madrid, Spain
| |
Collapse
|
2
|
Mahmoud AK, Abbas MT, Kamel MA, Farina JM, Pereyra M, Scalia IG, Barry T, Chao CJ, Marcotte F, Ayoub C, Scott RL, Majdalany DS, Arsanjani R. Current Management and Future Directions for Pulmonary Arterial Hypertension Associated with Congenital Heart Disease. J Pers Med 2023; 14:5. [PMID: 38276220 PMCID: PMC10817644 DOI: 10.3390/jpm14010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/12/2023] [Accepted: 12/16/2023] [Indexed: 01/27/2024] Open
Abstract
Current management of patients with congenital heart disease has increased their survival into adulthood. This is accompanied by potential cardiac complications, including pulmonary hypertension associated with congenital heart disease (PAH-CHD). PAH-CHD constitutes a challenging subgroup of pulmonary hypertension and requires expert management to improve quality of life and prognosis. Novel agents have shown a significant improvement in morbidity and mortality in patients with pulmonary arterial hypertension. However, the long-term effects of these medications on PAH-CHD patients remain somewhat uncertain, necessitating treatment plans largely founded on the clinical experience of the healthcare providers. The aim of this review is to summarize the current evidence and future perspectives regarding treatment strategies for PAH-CHD to help better guide management of this complex disease.
Collapse
Affiliation(s)
- Ahmed K. Mahmoud
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Mohammed Tiseer Abbas
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Moaz A. Kamel
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Juan M. Farina
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Isabel G. Scalia
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Timothy Barry
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Chieh-Ju Chao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Francois Marcotte
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Robert L. Scott
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - David S. Majdalany
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| |
Collapse
|
3
|
Mares A, Mukherjee D, Lange RA, Nickel NP. Targeted Therapies in Patients with Pulmonary Arterial Hypertension Due to Congenital Heart Disease. Curr Vasc Pharmacol 2022; 20:341-360. [PMID: 36125818 DOI: 10.2174/1570161120666220811150853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/08/2022] [Accepted: 06/08/2022] [Indexed: 01/25/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a devastating cardiovascular disease leading to right heart failure and death if untreated. Medical therapies for PAH have evolved substantially over the last decades and are associated with improvements in functional class, quality of life, and survival. PAH-targeted therapies now consist of multiple inhaled, oral, subcutaneous, and intravenous therapies targeting the phosphodiesterase, guanylate cyclase, endothelin and prostacyclin pathways. Patients with congenital heart disease (CHD) are at high risk of developing PAH and growing evidence exists that PAH-targeted therapy can be beneficial in PAH-CHD. However, the PAH-CHD patient population is challenging to treat due to the heterogeneity and complexity of their cardiac lesions and associated comorbidities. Furthermore, most high-quality randomized placebo-controlled trials investigating the effects of PAH-targeted therapies only included a minority of PAH-CHD patients. Few randomized, controlled trials have investigated the effects of PAH-targeted therapy in pre-specified PAH-CHD populations. Consequently, the results of these clinical trials cannot be extrapolated broadly to the PAH-CHD population. This review summarizes the data from high-quality clinical PAH treatment trials with a specific focus on the PAH-CHD population.
Collapse
Affiliation(s)
- Adriana Mares
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, 79905, USA
| | - Debabrata Mukherjee
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, 79905, USA.,Department of Internal Medicine, Division of Cardiology, Texas Tech University Health Sciences Center, El Paso, Texas, 79905, USA
| | - Richard A Lange
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, 79905, USA.,Department of Internal Medicine, Division of Cardiology, Texas Tech University Health Sciences Center, El Paso, Texas, 79905, USA
| | - Nils P Nickel
- Department of Internal Medicine, Division of Cardiology, Texas Tech University Health Sciences Center, El Paso, Texas, 79905, USA.,Department of Internal Medicine, Division of Pulmonology and Critical Care Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, 79905, USA
| |
Collapse
|
4
|
Selexipag in patients with complex or uncorrected congenital heart disease: Single centre experience. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
5
|
Arvanitaki A, Gatzoulis MA, Opotowsky AR, Khairy P, Dimopoulos K, Diller GP, Giannakoulas G, Brida M, Griselli M, Grünig E, Montanaro C, Alexander PD, Ameduri R, Mulder BJM, D'Alto M. Eisenmenger Syndrome: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79:1183-1198. [PMID: 35331414 DOI: 10.1016/j.jacc.2022.01.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/10/2022] [Accepted: 01/18/2022] [Indexed: 12/12/2022]
Abstract
Although major breakthroughs in the field of pediatric cardiology, cardiac surgery, intervention, and overall care improved the outlook of congenital heart disease, Eisenmenger syndrome (ES) is still encountered and remains a complex clinical entity with multisystem involvement, including secondary erythrocytosis, increased thrombotic and bleeding diathesis, high arrhythmogenic risk, progressive heart failure, and premature death. Clearly, care for ES is best delivered in multidisciplinary expert centers. In this review, we discuss the considerable recent progress in understanding the complex pathophysiology of ES, means of prognostication, and improvement in clinical outcomes achieved with pulmonary arterial hypertension-targeted therapies. Additionally, we delineate areas of uncertainty in various aspects of care, discuss gaps in current evidence, and review current status in less privileged countries and propose initiatives to reduce disease burden. Finally, we propose the application of emerging technologies to enhance the delivery and quality of health care related to ES and beyond.
Collapse
Affiliation(s)
- Alexandra Arvanitaki
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guy's and St Thomas's NHS Foundation Trust, Imperial College, London, United Kingdom; First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece; Department of Cardiology III - Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Michael A Gatzoulis
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guy's and St Thomas's NHS Foundation Trust, Imperial College, London, United Kingdom.
| | - Alexander R Opotowsky
- The Cincinnati Adult Congenital Heart Disease Program, Heart Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guy's and St Thomas's NHS Foundation Trust, Imperial College, London, United Kingdom
| | - Gerhard-Paul Diller
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guy's and St Thomas's NHS Foundation Trust, Imperial College, London, United Kingdom; Department of Cardiology III - Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Margarita Brida
- Division of Adult Congenital Heart Disease, Department of Cardiovascular Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Massimo Griselli
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guy's and St Thomas's NHS Foundation Trust, Imperial College, London, United Kingdom; Pediatric Cardiac Surgery and Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, and German Center of Lung Research (DZL), TLRC Heidelberg, Heidelberg, Germany
| | - Claudia Montanaro
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guy's and St Thomas's NHS Foundation Trust, Imperial College, London, United Kingdom
| | - Peter David Alexander
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guy's and St Thomas's NHS Foundation Trust, Imperial College, London, United Kingdom
| | - Rebecca Ameduri
- Pediatric Cardiac Surgery and Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Michele D'Alto
- Department of Cardiology, Monaldi Hospital - "L. Vanvitelli" University, Naples, Italy.
| |
Collapse
|