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Kozaily E, Akdogan ER, Dorsey NS, Tedford RJ. Management of Pulmonary Hypertension in the Context of Heart Failure with Preserved Ejection Fraction. Curr Hypertens Rep 2024; 26:291-306. [PMID: 38558124 DOI: 10.1007/s11906-024-01296-2] [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] [Accepted: 01/29/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE OF REVIEW To review the current evidence and modalities for treating pulmonary hypertension (PH) in heart failure with preserved ejection fraction (HFpEF). RECENT FINDINGS In recent years, several therapies have been developed that improve morbidity in HFpEF, though these studies have not specifically studied patients with PF-HFpEF. Multiple trials of therapies specifically targeting the pulmonary vasculature such as phosphodiesterase (PDE) inhibitors, prostacyclin analogs, endothelin receptor antagonists (ERA), and soluble guanylate cyclase stimulators have also been conducted. However, these therapies demonstrated lack of consistency in improving hemodynamics or functional outcomes in PH-HFpEF. There is limited evidence to support the use of pulmonary vasculature-targeting therapies in PH-HFpEF. The mainstay of therapy remains the treatment of the underlying HFpEF condition. There is emerging evidence that newer HF therapies such as sodium-glucose transporter 2 inhibitors and angiotensin-receptor-neprilysin inhibitors are associated with improved hemodynamics and quality of life of patients with PH-HFpEF. There is also a growing realization that more robust phenotyping PH and right ventricular (RV) function may hold promise for therapeutic strategies for patients with PH-HFpEF.
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Affiliation(s)
- Elie Kozaily
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Ecem Raziye Akdogan
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | | | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA.
- Advanced Heart Failure & Transplant Fellowship Training Program, Medical University of South Carolina (MUSC), 30 Courtenay Drive, BM215, MSC592, Charleston, SC, 29425, USA.
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Ameri P, Mercurio V, Pollesello P, Anker MS, Backs J, Bayes-Genis A, Borlaug BA, Burkhoff D, Caravita S, Chan SY, de Man F, Giannakoulas G, González A, Guazzi M, Hassoun PM, Hemnes AR, Maack C, Madden B, Melenovsky V, Müller OJ, Papp Z, Pullamsetti SS, Rainer PP, Redfield MM, Rich S, Schiattarella GG, Skaara H, Stellos K, Tedford RJ, Thum T, Vachiery JL, van der Meer P, Van Linthout S, Pruszczyk P, Seferovic P, Coats AJS, Metra M, Rosano G, Rosenkranz S, Tocchetti CG. A roadmap for therapeutic discovery in pulmonary hypertension associated with left heart failure. A scientific statement of the Heart Failure Association (HFA) of the ESC and the ESC Working Group on Pulmonary Circulation & Right Ventricular Function. Eur J Heart Fail 2024; 26:707-729. [PMID: 38639017 PMCID: PMC11182487 DOI: 10.1002/ejhf.3236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 02/23/2024] [Accepted: 03/28/2024] [Indexed: 04/20/2024] Open
Abstract
Pulmonary hypertension (PH) associated with left heart failure (LHF) (PH-LHF) is one of the most common causes of PH. It directly contributes to symptoms and reduced functional capacity and negatively affects right heart function, ultimately leading to a poor prognosis. There are no specific treatments for PH-LHF, despite the high number of drugs tested so far. This scientific document addresses the main knowledge gaps in PH-LHF with emphasis on pathophysiology and clinical trials. Key identified issues include better understanding of the role of pulmonary venous versus arteriolar remodelling, multidimensional phenotyping to recognize patient subgroups positioned to respond to different therapies, and conduct of rigorous pre-clinical studies combining small and large animal models. Advancements in these areas are expected to better inform the design of clinical trials and extend treatment options beyond those effective in pulmonary arterial hypertension. Enrichment strategies, endpoint assessments, and thorough haemodynamic studies, both at rest and during exercise, are proposed to play primary roles to optimize early-stage development of candidate therapies for PH-LHF.
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Affiliation(s)
- Pietro Ameri
- Department of Internal Medicine, University of Genova, Genoa, Italy
- Cardiac, Thoracic, and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Interdepartmental Center for Clinical and Translational Research (CIRCET), and Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Piero Pollesello
- Content and Communication, Branded Products, Orion Pharma, Espoo, Finland
| | - Markus S Anker
- Deutsches Herzzentrum der Charité, Klinik für Kardiologie, Angiologie und Intensivmedizin (Campus CBF), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Backs
- Institute of Experimental Cardiology, University Hospital Heidelberg, University of Heidelberg and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Barry A Borlaug
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Research Foundation, New York, NY, USA
| | | | - Sergio Caravita
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy
- Department of Cardiology, Istituto Auxologico Italiano IRCCS Ospedale San Luca, Milan, Italy
| | - Stephen Y Chan
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
| | - Frances de Man
- PHEniX laboratory, Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aránzazu González
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain
- CIBERCV, Madrid, Spain
| | - Marco Guazzi
- University of Milan, Milan, Italy
- Cardiology Division, San Paolo University Hospital, Milan, Italy
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cristoph Maack
- Comprehensive Heart Failure Center (CHFC) and Medical Clinic I, University Clinic Würzburg, Würzburg, Germany
| | | | - Vojtech Melenovsky
- Department of Cardiology, Institute for Clinical and Experimental Medicine - IKEM, Prague, Czech Republic
| | - Oliver J Müller
- Department of Internal Medicine V, University Hospital Schleswig-Holstein, and German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Zoltan Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Soni Savai Pullamsetti
- Department of Internal Medicine and Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig University, Giessen, Germany
| | - Peter P Rainer
- Division of Cardiology, Medical University of Graz, Graz, Austria
- BioTechMed Graz, Graz, Austria
- Department of Medicine, St. Johann in Tirol General Hospital, St. Johann in Tirol, Austria
| | | | - Stuart Rich
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gabriele G Schiattarella
- Max-Rubner Center (CMR), Department of Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Translational Approaches in Heart Failure and Cardiometabolic Disease, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Hall Skaara
- Pulmonary Hypertension Association Europe, Vienna, Austria
| | - Kostantinos Stellos
- Department of Cardiovascular Research, European Center for Angioscience (ECAS), Heidelberg University, Mannheim, Germany
- German Centre for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislauf-Forschung, DZHK), Heidelberg/Mannheim Partner Site, Heidelberg and Mannheim, Germany
- Department of Cardiology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
- Biosciences Institute, Vascular Biology and Medicine Theme, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
| | - Jean Luc Vachiery
- Department of Cardiology, Hopital Universitaire de Bruxelles Erasme, Brussels, Belgium
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sophie Van Linthout
- Berlin Institute of Health (BIH) at Charité, BIH Center for Regenerative Therapies, University of Medicine, Berlin, Germany
- German Center for Cardiovascular Research (DZHK, partner site Berlin), Berlin, Germany
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Petar Seferovic
- University of Belgrade Faculty of Medicine, Belgrade University Medical Center, Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | | | - Marco Metra
- Cardiology. ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Stephan Rosenkranz
- Department of Cardiology and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Interdepartmental Center for Clinical and Translational Research (CIRCET), and Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy
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Hirata Y, Tsuji T, Kotoku J, Sata M, Kusunose K. Echocardiographic artificial intelligence for pulmonary hypertension classification. Heart 2024; 110:586-593. [PMID: 38296266 DOI: 10.1136/heartjnl-2023-323320] [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: 08/16/2023] [Accepted: 11/30/2023] [Indexed: 03/24/2024] Open
Abstract
OBJECTIVE The classification of pulmonary hypertension (PH) is crucial for determining the appropriate therapeutic strategy. We investigated whether machine learning (ML) algorithms may assist in echocardiographic PH prediction, where current guidelines recommend integrating several different parameters. METHODS We obtained physical and echocardiographic data from 885 patients who underwent right heart catheterisation (RHC). Patients were classified into three groups: non-PH, precapillary PH and postcapillary PH, based on values obtained from RHC. Using 24 parameters, we created predictive models employing four different classifiers and selected the one with the highest area under the curve. We then calculated the macro-average classification accuracy for PH on the derivation cohort (n=720) and prospective validation data set (n=165), comparing the results with guideline-based echocardiographic assessment obtained from each cohort. RESULTS Logistic regression with elastic net regularisation had the highest classification accuracy, with areas under the curves of 0.789, 0.766 and 0.742 for normal, precapillary PH and postcapillary PH, respectively. The ML model demonstrated significantly better predictive accuracy than the guideline-based echocardiographic assessment in the derivation cohort (59.4% vs 51.6%, p<0.01). In the independent validation data set, the ML model's accuracy was comparable to the guideline-based PH classification (59.4% vs 57.8%, p=0.638). CONCLUSIONS This preliminary study suggests promising potential for our ML model in predicting echocardiographic PH. Further research and validation are needed to fully assess its clinical utility in PH diagnosis and treatment decision-making.
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Affiliation(s)
- Yukina Hirata
- Ultrasound Examination center, Tokushima University Hospital, Tokushima, Japan
| | - Takumasa Tsuji
- Department of Radiological Technology, Teikyo University, Itabashi-ku, Tokyo, Japan
| | - Jun'ichi Kotoku
- Department of Radiological Technology, Teikyo University, Itabashi-ku, Tokyo, Japan
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Kenya Kusunose
- Department of Cardiovascular Medicine, Nephrology, and Neurology, University of the Ryukyus, Uehara, Okinawa, Japan
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Goncharova N, Lapshin K, Berezina A, Simakova M, Marichev A, Zlobina I, Marukyan N, Malikov K, Aseeva A, Zaitsev V, Moiseeva O. Elderly Patients with Idiopathic Pulmonary Hypertension: Clinical Characteristics, Survival, and Risk Stratification in a Single-Center Prospective Registry. Life (Basel) 2024; 14:259. [PMID: 38398770 PMCID: PMC10890450 DOI: 10.3390/life14020259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 02/09/2024] [Accepted: 02/11/2024] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION The predictive value of the risk stratification scales in elderly patients with IPAH might differ from that in younger patients. It is unknown whether young and older IPAH patients have the same survival dependence on PAH-specific therapy numbers. The aim of this study was to evaluate the prognostic relevance of risk stratification scales and PAH medication numbers in elderly IPAH patients in comparison with young IPAH patients. MATERIALS AND METHODS A total of 119 patients from a prospective single-center PAH registry were divided into group I < 60 years old (n = 89) and group II ≥ 60 years old (n = 30). ESC/ERS, REVEAL, and REVEAL 2.0 risk stratification scores were assessed at baseline, as well as H2FpEF score and survival at follow-up. RESULTS During a mean follow-up period of 2.9 years (1.63; 6.0), 42 (35.3%) patients died; at 1, 2, 3, 5, 7, and 10 years, survival was 95%, 88.6%, 78.5%, 61.7%, 48.5%, and 33.7%, respectively. No survival differences were observed between the two groups, despite the use of monotherapy in the elderly patients. The best predictive REVEAL value in elderly patients (IPAH patients ≥ 60 years) was AUC 0.73 (0.56-0.91), p = 0.03; and in patients with LHD comorbidities in the entire cohort, it was AUC 0.73 (0.59-0.87), p < 0.009. Factors independently associated with death in the entire cohort were CKD (p = 0.01, HR 0.2), the right-to-left ventricle dimension ratio (p = 0.0047, HR 5.97), and NT-proBNP > 1400 pg/mL (p = 0.008, HR 3.18). CONCLUSION Risk stratification in the elderly IPAH patients requires a fundamentally different approach than that of younger patients, taking into account the initial limitations in physical performance and comorbidities that interfere with current assessment scores. The REVEAL score reliably stratifies patients at any age and LHD comorbidities. The initial monotherapy seems to be reasonable in patients over 60 years. Selection tools for initial combination PAH therapy in older IPAH patients with comorbidities need to be validated in prospective observational studies.
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Affiliation(s)
- Natalia Goncharova
- Almazov National Medical Research Centre, Ministry of Health of Russia, Saint Petersburg 197341, Russia (A.B.); (A.M.); (I.Z.); (N.M.); (K.M.); (A.A.); (V.Z.); (O.M.)
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Harder EM, Divo MJ, Washko GR, Leopold JA, Rahaghi FN, Waxman AB. Implications of Mean Pulmonary Arterial Wedge Pressure Trajectories in Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2024; 209:316-324. [PMID: 37939220 PMCID: PMC10840771 DOI: 10.1164/rccm.202306-1072oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/18/2023] [Indexed: 11/10/2023] Open
Abstract
Rationale: The mean pulmonary arterial wedge pressure (mPAWP) is the critical hemodynamic factor differentiating group 1 pulmonary arterial hypertension (PAH) from group 2 pulmonary hypertension associated with left heart disease. Despite the discrepancy between the mPAWP upper physiologic normal and current PAH definitions, the implications of the initial mPAWP for PAH clinical trajectory are poorly understood. Objectives: To model longitudinal mPAWP trajectories in PAH over 10 years and examine the clinical and hemodynamic factors associated with trajectory membership. Methods: Adult patients with PAH with two or more right heart catheterizations were identified from a multiinstitution healthcare system in eastern Massachusetts. mPAWP trajectories were constructed via group-based trajectory modeling. Feature selection was performed in least absolute shrinkage and selection operator regression. Logistic regression was used to assess associations between trajectory membership, baseline characteristics, and transplant-free survival. Measurements and Main Results: Among 301 patients with PAH, there were two distinct mPAWP trajectories, termed "mPAWP-high" (n = 71; 23.6%) and "mPAWP-low" (n = 230; 76.4%), based on the ultimate mPAWP value. Initial mPAWP clustered around median 12 mm Hg (interquartile range [IQR], 8-14 mm Hg) in the mPAWP-high and 9 mm Hg (IQR, 6-11 mm Hg) in the mPAWP-low trajectories (P < 0.001). After feature selection, initial mPAWP ⩾12 mm Hg predicted an mPAWP-high trajectory (odds ratio, 3.2; 95% confidence interval, 1.4-6.1; P = 0.0006). An mPAWP-high trajectory was associated with shorter transplant-free survival (vs. mPAWP-low, median, 7.8 vs. 11.3 yr; log-rank P = 0.017; age-adjusted P = 0.217). Conclusions: Over 10 years, the mPAWP followed two distinct trajectories, with 25% evolving into group 2 pulmonary hypertension physiology. Using routine baseline data, longitudinal mPAWP trajectory could be predicted accurately, with initial mPAWP ⩾12 mm Hg as one of the strongest predictors.
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Affiliation(s)
| | | | | | - Jane A. Leopold
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Vaidy A, Vahdatpour CA, Mazurek J. Exercise Testing in Patients with Pulmonary Hypertension. J Clin Med 2024; 13:795. [PMID: 38337493 PMCID: PMC10855991 DOI: 10.3390/jcm13030795] [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: 12/21/2023] [Revised: 01/23/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Pulmonary hypertension (PH), defined by a mean pulmonary artery pressure of >20 mm Hg, often presents with non-specific symptoms such as dyspnea and exercise intolerance, making it difficult to diagnose early before the onset of right heart dysfunction. Therefore, exercise testing can be of great utility for clinicians who are evaluating patients with an unclear etiology of exercise intolerance by helping identify the underlying mechanisms of their disease. The presence of PH is associated with adverse clinical outcomes, with distinct differences and patterns in the cardiovascular and ventilatory responses to exercise across various PH phenotypes. We discuss the role of exercise-invasive hemodynamic testing, cardiopulmonary exercise testing, and exercise stress echocardiography modalities across the spectrum of PH.
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Affiliation(s)
- Anika Vaidy
- Division of Cardiology, School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Cyrus A. Vahdatpour
- Division of Pulmonary Medicine, School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Jeremy Mazurek
- Division of Cardiology, School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
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Riley JM, Fradin JJ, Russ DH, Warner ED, Brailovsky Y, Rajapreyar I. Post-Capillary Pulmonary Hypertension: Clinical Review. J Clin Med 2024; 13:625. [PMID: 38276131 PMCID: PMC10816629 DOI: 10.3390/jcm13020625] [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: 12/04/2023] [Revised: 01/13/2024] [Accepted: 01/20/2024] [Indexed: 01/27/2024] Open
Abstract
Pulmonary hypertension (PH) caused by left heart disease, also known as post-capillary PH, is the most common etiology of PH. Left heart disease due to systolic dysfunction or heart failure with preserved ejection fraction, valvular heart disease, and left atrial myopathy due to atrial fibrillation are causes of post-capillary PH. Elevated left-sided filling pressures cause pulmonary venous congestion due to backward transmission of pressures and post-capillary PH. In advanced left-sided heart disease or valvular heart disease, chronic uncontrolled venous congestion may lead to remodeling of the pulmonary arterial system, causing combined pre-capillary and post-capillary PH. The hemodynamic definition of post-capillary PH includes a mean pulmonary arterial pressure > 20 mmHg, pulmonary vascular resistance < 3 Wood units, and pulmonary capillary wedge pressure > 15 mmHg. Echocardiography is important in the identification and management of the underlying cause of post-capillary PH. Management of post-capillary PH is focused on the treatment of the underlying condition. Strategies are geared towards pharmacotherapy and guideline-directed medical therapy for heart failure, surgical or percutaneous management of valvular disorders, and control of modifiable risk factors and comorbid conditions. Referral to centers with advanced heart and pulmonary teams has shown to improve morbidity and mortality. There is emerging interest in the use of targeted agents classically used in pulmonary arterial hypertension, but current data remain limited and conflicting. This review aims to serve as a comprehensive summary of postcapillary PH and its etiologies, pathophysiology, diagnosis, and management, particularly as it pertains to advanced heart failure.
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Affiliation(s)
- Joshua M. Riley
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA 19147, USA; (J.M.R.)
| | - James J. Fradin
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19147, USA
| | - Douglas H. Russ
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA 19147, USA; (J.M.R.)
| | - Eric D. Warner
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA 19147, USA; (J.M.R.)
| | - Yevgeniy Brailovsky
- Jefferson Heart Institute, Thomas Jefferson University Hospital, Philadelphia, PA 19147, USA;
| | - Indranee Rajapreyar
- Jefferson Heart Institute, Thomas Jefferson University Hospital, Philadelphia, PA 19147, USA;
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Vaidy A, O'Corragain O, Vaidya A. Diagnosis and Management of Pulmonary Hypertension and Right Ventricular Failure in the Cardiovascular Intensive Care Unit. Crit Care Clin 2024; 40:121-135. [PMID: 37973349 DOI: 10.1016/j.ccc.2023.05.003] [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] [Indexed: 11/19/2023]
Abstract
Pulmonary hypertension (PH) encompasses a broad range of conditions, including pulmonary artery hypertension, left-sided heart disease, and pulmonary and thromboembolic disorders. Successful diagnosis and management rely on an integrated clinical assessment of the patient's physiology and right heart function. Right ventricular (RV) heart failure is often a result of PH, but may result from varying abnormalities in preload, afterload, and intrinsic myocardial dysfunction, which require distinct management strategies. Consideration of an individual's hemodynamic phenotype and physiologic circumstances is paramount in management of PH and RV failure, particularly when there is clinical instability in the intensive care setting.
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Affiliation(s)
- Anika Vaidy
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Division of Cardiology, Temple University Hospital, 9th floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | | | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Division of Cardiology, Temple University Hospital, 9th floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA.
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Xu W, Deng M, Xi L, Liu A, Yang H, Tao X, Huang Q, Wang J, Xie W, Liu M. Comparison of cardiovascular metrics on computed tomography pulmonary angiography of the updated and old diagnostic criteria for pulmonary hypertension in patients with chronic thromboembolic pulmonary hypertension. Quant Imaging Med Surg 2023; 13:7910-7923. [PMID: 38106317 PMCID: PMC10721984 DOI: 10.21037/qims-23-250] [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: 02/28/2023] [Accepted: 09/07/2023] [Indexed: 12/19/2023]
Abstract
Background In the 2022 European Society of Cardiology (ESC) and the European Respiratory Society (ERS) guidelines, the diagnostic criteria for pulmonary hypertension (PH) included a reduced mean pulmonary artery pressure (mPAP) of 20 mmHg (mPAP >20 mmHg). This study aimed to reassess cardiovascular metrics on computed tomography pulmonary angiography (CTPA) for chronic thromboembolic pulmonary hypertension (CTEPH) to optimize the timely diagnosis of patients with suspected PH. Methods Patients with suspected CTEPH who underwent CTPA and right heart catheterization (RHC) between January 2019 and December 2022 in China-Japan Friendship Hospital were retrospectively included. They were grouped into CTEPH and non-PH groups according to the new and old criteria (2022 and 2015 ESC/ERS guidelines) for the diagnosis of PH. Cardiovascular metrics including the main pulmonary artery diameter (MPAd), Cobb angle, and right ventricular free wall thickness (RVWT), among others, were measured. The correlation of these metrics with hemodynamic data was analyzed with Spearman rank correlation analysis, while the differences in cardiovascular metrics between the updated (mPAP >20 mmHg) and old PH criteria (mPAP ≥25 mmHg) were compared with independent samples t-test or the Mann-Whitney test. Receiver operator characteristic (ROC) curve analysis was performed for the prediction model. Results The study enrolled 180 patients (males n=86; age 55.5±12.0 years old). According to the old guidelines, 119 patients were placed into the PH group (mPAP ≥25 mmHg) , while according to the new guidelines, 130 patients were placed into the PH group (mPAP >20 mmHg). Cardiovascular metrics on CTPA between the updated and old guidelines were comparable (P>0.05). Compared to other metrics, an MPAd of 30.4 mm exhibited the highest area under the curve (AUC: 0.934±0.021), with a sensitivity of 0.88 and specificity of 0.90. MPAd [odds ratio (OR) =1.271], transverse diameter of the right ventricle (RVtd; OR =1.176), Cobb angle (OR =1.108), and RVWT (OR =3.655) were independent factors for diagnosing CTEPH (P<0.05). Cobb angle, right and left ventricular transverse diameter ratio, and right and left ventricular area ratio moderately correlated with mPAP (r=0.586, r=0.583, r=0.629) and pulmonary vascular resistance (PVR) (r=0.613, r=0.593, r=0.642). Conclusions Cardiovascular metrics on CTPA were comparable between the new and old guidelines for CTEPH diagnosis. Cardiovascular metrics on CTPA can noninvasively assess the hemodynamics of patients with CTEPH.
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Affiliation(s)
- Wenqing Xu
- The Department of Radiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Mei Deng
- The Department of Radiology, China-Japan Friendship Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Linfeng Xi
- The Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital National Center for Respiratory Medicine, Beijing, China
| | - Anqi Liu
- The Department of Radiology, China-Japan Friendship Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haoyu Yang
- The Department of Radiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Xincao Tao
- The Department of Radiology, China-Japan Friendship Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiang Huang
- The Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital National Center for Respiratory Medicine, Beijing, China
| | - Jinzhi Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wanmu Xie
- The Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital National Center for Respiratory Medicine, Beijing, China
| | - Min Liu
- The Department of Radiology, China-Japan Friendship Hospital, Beijing, China
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Labrada L, Romero C, Sadek A, Belardo D, Raza Y, Forfia P. Intravenous Diuresis in Severe Precapillary Pulmonary-Hypertension-Related Right Heart Failure: Effects on Renal Function and Blood Pressure. J Clin Med 2023; 12:7149. [PMID: 38002761 PMCID: PMC10671890 DOI: 10.3390/jcm12227149] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/07/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
In patients with right heart failure (RHF) and pulmonary hypertension (PH), classical teaching often advises cautious diuresis in the setting of 'preload dependence' to avoid renal injury and hemodynamic compromise. However, while this physiology may hold true in some clinical settings, such as acute ischemia with right ventricular infarction, it cannot necessarily be extended to PH-related RHF. Rather, in patients with precapillary PH and decompensated RHF, diuresis aimed to decongest the right heart and systemic venous system may be directly beneficial. This study aimed to evaluate the effects of diuresis on renal function and blood pressure in patients with severe precapillary PH. A retrospective chart review was conducted on 62 patients with severe precapillary PH admitted for decompensated RHF. The hemodynamic phenotype of these patients was characterized by invasive hemodynamics and echocardiographic data. Laboratory and hemodynamic data were collected at both admission and discharge. After large-volume diuresis in this patient population, there was an improvement in both glomerular filtration rate and creatinine. While there was a decline in blood pressure after diuresis, this was not clinically significant, given the blood pressure remained in a normal range with improvement in renal function. In conclusion, this study demonstrated that despite concern for preload dependence, significant diuresis in patients with acute decompensated RHF from precapillary PH is not only safe but beneficial.
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Affiliation(s)
- Lyana Labrada
- Division of Cardiology, Temple University Hospital, Philadelphia, PA 19140, USA; (L.L.); (A.S.)
| | - Carlos Romero
- Division of Cardiology, Temple University Hospital, Philadelphia, PA 19140, USA; (L.L.); (A.S.)
| | - Ahmed Sadek
- Division of Cardiology, Temple University Hospital, Philadelphia, PA 19140, USA; (L.L.); (A.S.)
| | | | - Yasmin Raza
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Paul Forfia
- Division of Cardiology, Temple University Hospital, Philadelphia, PA 19140, USA; (L.L.); (A.S.)
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11
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Tello K, Richter MJ, Kremer N, Gall H, Egenlauf B, Sorichter S, Heberling M, Douschan P, Hager A, Yogeswaran A, Behr J, Xanthouli P, Held M. [Diagnostic Algorithm and Screening of Pulmonary Hypertension]. Pneumologie 2023; 77:871-889. [PMID: 37963477 DOI: 10.1055/a-2145-4678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
The new guidelines for the diagnosis and treatment of pulmonary hypertension include a new diagnostic algorithm and provide specific recommendations for the required diagnostic procedures, including screening methods. These recommendations are commented on by national experts under the auspices of the DACH. These comments provide additional decision support and background information, serving as a further guide for the complex diagnosis of pulmonary hypertension.
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Affiliation(s)
- Khodr Tello
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Manuel J Richter
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Nils Kremer
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Henning Gall
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Benjamin Egenlauf
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland, Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Stephan Sorichter
- Klinik für Pneumologie und Beatmungsmedizin, St.-Josefskrankenhaus, Freiburg im Breisgau, Deutschland
| | - Melanie Heberling
- Universitätsklinikum Dresden, Med. Klinik I, Pneumologie, Dresden, Deutschland
| | - Philipp Douschan
- Abteilung für Pulmonologie, Universitätsklinik für Innere Medizin, Graz, Österreich; Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Österreich
| | - Alfred Hager
- Department of Paediatric Cardiology and Congenital Heart Defects, Deutsches Herzzentrum München, München, Deutschland
| | - Athiththan Yogeswaran
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Jürgen Behr
- LMU Klinikum München, Medizinische Klinik und Poliklinik V, München, Deutschland. Comprehensive Pneumology Center (CPC-M), Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Panagiota Xanthouli
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland, Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Matthias Held
- Klinikum Würzburg Mitte, Medizinische Klinik Schwerpunkt Pneumologie & Beatmungsmedizin, Würzburg, Deutschland
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12
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Vorovich E, Schilling JD. Raising the Bar: Setting a New Standard for Invasive Hemodynamics in Heart Failure. J Card Fail 2023; 29:1519-1521. [PMID: 37661053 DOI: 10.1016/j.cardfail.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/09/2023] [Indexed: 09/05/2023]
Affiliation(s)
- Esther Vorovich
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Joel D Schilling
- Center for Cardiovascular Research, Washington University School of Medicine, St. Louis, Missouri; Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
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13
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Wernhart S, Goertz A, Hedderich J, Papathanasiou M, Hoffmann J, Rassaf T, Luedike P. Diastolic exercise stress testing in heart failure with preserved ejection fraction: The DEST-HF study. Eur J Heart Fail 2023; 25:1768-1780. [PMID: 37565370 DOI: 10.1002/ejhf.2995] [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: 05/03/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 08/12/2023] Open
Abstract
AIMS Pulmonary capillary wedge pressure (PAWP) ≥25 mmHg during bicycle ergometry is recommended to uncover occult heart failure with preserved ejection fraction. We hypothesized that PAWP increase would differ in available diastolic stress tests and that the margin of PAWP ≥25 mmHg would only be reliably achieved through ergometry. METHODS AND RESULTS We conducted a prospective, single-arm study in patients with an intermediate risk for heart failure with preserved ejection fraction according to the ESC HFA-PEFF score. A total of 19 patients underwent four stress test modalities in randomized order: leg raise, fluid challenge, handgrip, and bicycle ergometry. The primary outcome was the difference (Δ) between resting and exercise PAWP in each modality. Secondary outcomes were differences (Δ) in mean pulmonary artery pressure (mPAP), cardiac output (CO), as well as the ratios between mPAP and PAWP to CO. Compared to resting values, passive leg raise (Δ7.7 ± 8.0 mmHg, p = 0.030), fluid challenge (Δ9.2 ± 6.4 mmHg, p = 0.003), dynamic handgrip (Δ9.6 ± 7.5 mmHg, p = 0.002), and bicycle ergometry (Δ22.3 ± 5.0 mmHg, p < 0.001) uncovered increased PAWP during exercise. Amongst these, bicycle ergometry also demonstrated the highest ΔmPAP (27.2 ± 7.1 mmHg, p < 0.001), ΔCO (3.3 ± 2.6 L/min, p < 0.001), ΔmPAP/CO ratio (2.3 ± 2.0 mmHg/L/min, p < 0.001), and ΔPAWP/CO ratio (2.2 ± 1.4 mmHg/L/min, p < 0.001) compared to other modalities. PAWP ≥25 mmHg was only reliably achieved in bicycle ergometry (31.1 ± 3.9 mmHg). In all other modalities only 10.5% of patients achieved PAWP ≥25 mmHg (handgrip 18.4 ± 6.6 mmHg, fluid 18.1 ± 5.6 mmHg, leg raise 16.5 ± 7.0 mmHg). CONCLUSIONS We demonstrate that bicycle ergometry exhibits a distinct haemodynamic response with higher increase of PAWP compared to other modalities. This finding needs to be considered for valid detection of exercise PAWP ≥25 mmHg when non-bicycle tests remain inconclusive.
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Affiliation(s)
- Simon Wernhart
- Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, West German Heart and Vascular Center, Essen, Germany
| | - Annika Goertz
- Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, West German Heart and Vascular Center, Essen, Germany
| | | | - Maria Papathanasiou
- Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, West German Heart and Vascular Center, Essen, Germany
| | - Julia Hoffmann
- Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, West German Heart and Vascular Center, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, West German Heart and Vascular Center, Essen, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, West German Heart and Vascular Center, Essen, Germany
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14
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Wu Y, Su X, Wang J, Zhang H, Zeng X, Zhang S, Zhang N, Wu K. Can Pulmonary Arterial Compliance Be a Prognostic Marker for Pulmonary Hypertension? Am J Respir Crit Care Med 2023; 208:822-823. [PMID: 37562031 PMCID: PMC10563186 DOI: 10.1164/rccm.202306-1076le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/09/2023] [Indexed: 08/12/2023] Open
Affiliation(s)
- Yanjuan Wu
- Sleep Medicine Center, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, National Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaofen Su
- Sleep Medicine Center, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, National Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jingcun Wang
- Sleep Medicine Center, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, National Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Haojie Zhang
- Sleep Medicine Center, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, National Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiangxia Zeng
- Sleep Medicine Center, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, National Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Sun Zhang
- Sleep Medicine Center, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, National Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Nuofu Zhang
- Sleep Medicine Center, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, National Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Kang Wu
- Sleep Medicine Center, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, National Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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15
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Abstract
PURPOSE OF REVIEW Pulmonary hypertension associated with left heart disease (PHLHD) is common and associated with adverse prognosis. Proper diagnosis is critical to avoid inappropriate treatment. Practical approaches to noninvasive diagnosis are available, though invasive hemodynamics including volume loading or exercise are often necessary for definitive diagnosis. Treatment strategies and research in the field is rapidly evolving. RECENT FINDINGS Combined pre and post capillary pulmonary hypertension is associated with remodeling of the pulmonary vasculature that is proportional to the severity of the pulmonary hypertension. Even quite mild elevation of pulmonary vascular resistance (PVR), (greater than 2.0 Wood units (WU)) is associated with adverse outcome. Guideline-directed medical therapy (GDMT) for left heart failure has rapidly evolved, including approval of SGLT2 inhibitors for treatment of heart failure with preserved ejection fraction (HFpEF). However, full implementation of GDMT is lagging. Utilization of implanted pulmonary artery pressure monitoring can facilitate patient management in selected patient phenotypes and has been utilized to demonstrate improvement in pulmonary pressures with emerging therapies in HFpEF including SGLT2 inhibitors and sacubitril/valsartan. A variety of shunt devices to create a left-to-right shunt in order to decompress the left heart are available or undergoing clinical trials. There is concern that there could be adverse response to such devices in patients who have even mild elevation of pulmonary vascular resistance. Sleep disordered breathing is common in PHLHD and should be aggressively sought out and treated. SUMMARY Even mild elevation in pulmonary vascular resistance is associated with adverse outcome. A systematic approach to diagnosis of PHLHD is essential. Guideline-directed medical therapy for PHLHD prioritizes optimal management of the left heart disease. Pulmonary artery pressure sensors are useful in selected patients.
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Affiliation(s)
- Robert P Frantz
- Department of Cardiovascular Medicine, Rochester, Minnesota, USA
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16
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Johnson S, Sommer N, Cox-Flaherty K, Weissmann N, Ventetuolo CE, Maron BA. Pulmonary Hypertension: A Contemporary Review. Am J Respir Crit Care Med 2023; 208:528-548. [PMID: 37450768 PMCID: PMC10492255 DOI: 10.1164/rccm.202302-0327so] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/14/2023] [Indexed: 07/18/2023] Open
Abstract
Major advances in pulmonary arterial hypertension, pulmonary hypertension (PH) associated with lung disease, and chronic thromboembolic PH cast new light on the pathogenetic mechanisms, epidemiology, diagnostic approach, and therapeutic armamentarium for pulmonary vascular disease. Here, we summarize key basic, translational, and clinical PH reports, emphasizing findings that build on current state-of-the-art research. This review includes cutting-edge progress in translational pulmonary vascular biology, with a guide to the diagnosis of patients in clinical practice, incorporating recent PH definition revisions that continue emphasis on early detection of disease. PH management is reviewed including an overview of the evolving considerations for the approach to treatment of PH in patients with cardiopulmonary comorbidities, as well as a discussion of the groundbreaking sotatercept data for the treatment of pulmonary arterial hypertension.
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Affiliation(s)
- Shelsey Johnson
- The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical Care, Boston University School of Medicine, Boston, Massachusetts
- Department of Pulmonary and Critical Care Medicine and
| | - Natascha Sommer
- Excellence Cluster Cardiopulmonary Institute, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | | | - Norbert Weissmann
- Excellence Cluster Cardiopulmonary Institute, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | - Corey E. Ventetuolo
- Department of Medicine and
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island
| | - Bradley A. Maron
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
- Department of Cardiology and Department of Pulmonary, Allergy, Sleep, and Critical Care Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland; and
- The University of Maryland-Institute for Health Computing, Bethesda, Maryland
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17
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Labrada L, Vaidy A, Vaidya A. Right ventricular assessment in pulmonary hypertension. Curr Opin Pulm Med 2023; 29:348-354. [PMID: 37410491 PMCID: PMC10408730 DOI: 10.1097/mcp.0000000000000980] [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] [Indexed: 07/07/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview of assessment of right ventricular function in the context of pulmonary hypertension and pulmonary arterial hypertension (PAH). We will review unique features of right ventricular anatomy, delineation of cause of pulmonary hypertension through careful right ventricular assessment, echocardiographic and hemodynamic evaluation, and the importance of this assessment in prognosis. RECENT FINDINGS The importance of performance in prognosis and risk assessment in patients with pulmonary hypertension has been continually emphasized in ongoing research. Representative parameters of right ventricular function have been shown to be predictive of prognosis in patients with pulmonary hypertension. Further, the importance of serial right ventricular assessment in risk assessment and prognosis has remained an emerging theme. SUMMARY Careful evaluation of right ventricular function is paramount in assessing the cause of pulmonary hypertension and severity of disease. Further, it has prognostic significance, as many representative parameters of right ventricular function have been linked with mortality. In our opinion, right ventricular function should be assessed serially throughout the course of treatment in pulmonary hypertension, and baseline parameters in addition to dynamic changes should be incorporated into risk assessment. Achieving normal or near-normal right ventricular performance may serve as a principal goal in the treatment of pulmonary hypertension.
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Affiliation(s)
- Lyana Labrada
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Division of Cardiology, Temple University Hospital, Philadelphia, Pennsylvania, USA
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18
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Wu Y, Tian P, Liang L, Chen Y, Feng J, Huang B, Huang L, Zhao X, Wang J, Guan J, Li X, Zhang Y, Zhang J. Combined use of right ventricular coupling and pulmonary arterial elastance as a comprehensive stratification approach for right ventricular function. Clin Transl Sci 2023; 16:1582-1593. [PMID: 37326126 PMCID: PMC10499407 DOI: 10.1111/cts.13568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/10/2023] [Accepted: 05/29/2023] [Indexed: 06/17/2023] Open
Abstract
Right ventricular (RV)-pulmonary arterial uncoupling is the consequence of increased afterload and/or decreased RV contractility. However, the combination of arterial elastance (Ea) and end-systolic elastance (Ees)/Ea ratio to assess RV function is unclear. We hypothesized that the combination of both could comprehensively assess RV function and refine risk stratification. The median Ees/Ea ratio (0.80) and Ea (0.59 mmHg/mL) were used to classify 124 patients with advanced heart failure into four groups. RV systolic pressure differential was defined as end-systolic pressure (ESP) minus beginning-systolic pressure (BSP). Patients among different subsets showed dissimilar New York Heart Association functional class (V = 0.303, p = 0.010), distinct tricuspid annular plane systolic excursion/ pulmonary artery systolic pressure (mm/mmHg; 0.65 vs. 0.44 vs. 0.32 vs. 0.26, p < 0.001), and diverse prevalence of pulmonary hypertension (33.3% vs. 35% vs. 90% vs. 97.6%, p < 0.001). By multivariate analysis, Ees/Ea ratio (hazard ratio [HR] 0.225, p = 0.004) and Ea (HR 2.194, p = 0.003) were independently associated with event-free survival. Patients with Ees/Ea ratio greater than or equal to 0.80 and Ea less than 0.59 mmHg/mL had better outcomes (p < 0.05). In patients with Ees/Ea ratio greater than or equal to 0.80, those with Ea greater than or equal to 0.59 mmHg/mL had a higher adverse outcome risk (p < 0.05). Ees/Ea ratio less than or equal to 0.80 was associated with adverse outcomes, even when Ea was less than 0.59 mmHg/mL (p < 0.05). Approximately 86% of patients with ESP-BSP greater than 5 mmHg had an Ees/Ea ratio less than or equal to 0.80 and/or an Ea greater than or equal to 0.59 mmHg/mL (V = 0.336, p = 0.001). Combined use of Ees/Ea ratio and Ea could be a comprehensive approach to assessing RV function and predicting outcomes. An exploratory analysis demonstrated that Ees/Ea ratio and Ea might be roughly estimated based on RV systolic pressure differential.
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Affiliation(s)
- Yihang Wu
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Pengchao Tian
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Lin Liang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Yuyi Chen
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Jiayu Feng
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Boping Huang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Liyan Huang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Xuemei Zhao
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Jing Wang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Jingyuan Guan
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Xinqing Li
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Yuhui Zhang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Jian Zhang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
- Key Laboratory of Clinical Research for Cardiovascular MedicationsNational Health CommitteeBeijingChina
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19
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Hajduczok AG, Houston BA, Tedford RJ. More Than a Number: What We Can Learn From Hemodynamic Waveforms. Chest 2023; 164:283-286. [PMID: 37558322 DOI: 10.1016/j.chest.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 05/03/2023] [Indexed: 08/11/2023] Open
Affiliation(s)
- Alexander G Hajduczok
- Department of Medicine, Division of Cardiology, Thomas Jefferson University, Philadelphia, PA
| | - Brian A Houston
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Ryan J Tedford
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC.
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20
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Liu R, Yuan T, Wang R, Gong D, Wang S, Du G, Fang L. Insights into Endothelin Receptors in Pulmonary Hypertension. Int J Mol Sci 2023; 24:10206. [PMID: 37373355 DOI: 10.3390/ijms241210206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Pulmonary hypertension (PH) is a disease which affects the cardiopulmonary system; it is defined as a mean pulmonary artery pressure (mPAP) > 20 mmHg as measured by right heart catheterization at rest, and is caused by complex and diverse mechanisms. In response to stimuli such as hypoxia and ischemia, the expression and synthesis of endothelin (ET) increase, leading to the activation of various signaling pathways downstream of it and producing effects such as the induction of abnormal vascular proliferation during the development of the disease. This paper reviews the regulation of endothelin receptors and their pathways in normal physiological processes and disease processes, and describes the mechanistic roles of ET receptor antagonists that are currently approved and used in clinical studies. Current clinical researches on ET are focused on the development of multi-target combinations and novel delivery methods to improve efficacy and patient compliance while reducing side effects. In this review, future research directions and trends of ET targets are described, including monotherapy and precision medicine.
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Affiliation(s)
- Ruiqi Liu
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
- Beijing Key Laboratory of Drug Targets Identification and Drug Screening, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | - Tianyi Yuan
- Beijing Key Laboratory of Drug Targets Identification and Drug Screening, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | - Ranran Wang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
- Beijing Key Laboratory of Drug Targets Identification and Drug Screening, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | - Difei Gong
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
- Beijing Key Laboratory of Drug Targets Identification and Drug Screening, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | - Shoubao Wang
- Beijing Key Laboratory of Drug Targets Identification and Drug Screening, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | - Guanhua Du
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | - Lianhua Fang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
- Beijing Key Laboratory of Drug Targets Identification and Drug Screening, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
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21
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Martínez-Solano J, Ortiz-Bautista C, Gutiérrez-Ibañes E, García-Cosío MD, Sarnago-Cebada F, Díaz-Molina B, Pascual I, Gómez-Bueno M, Calviño-Santos R, Gómez-Hospital JA, García-Lara J, de la Fuente-Galán L, Mirabet-Pérez S, Martínez-Sellés M. Optical coherence tomography assessment of pulmonary vascular remodeling in advanced heart failure. The OCTOPUS-CHF study. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:312-321. [PMID: 36155847 DOI: 10.1016/j.rec.2022.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 09/06/2022] [Indexed: 04/29/2023]
Abstract
INTRODUCTION AND OBJECTIVES Pulmonary vascular remodeling is common among patients with advanced heart failure. Right heart catheterization is the gold standard to assess pulmonary hypertension, but is limited by indirect measurement assumptions, a steady-flow view, load-dependency, and interpretation variability. We aimed to assess pulmonary vascular remodeling with intravascular optical coherence tomography (OCT) and to study its correlation with hemodynamic data. METHODS This observational, prospective, multicenter study recruited 100 patients with advanced heart failure referred for heart transplant evaluation. All patients underwent right heart catheterization together with OCT evaluation of a subsegmentary pulmonary artery. RESULTS OCT could be performed and properly analyzed in 90 patients. Median age was 57.50 [interquartile range, 48.75-63.25] years and 71 (78.88%) were men. The most frequent underlying heart condition was nonischemic dilated cardiomyopathy (33 patients [36.66%]). Vascular wall thickness significantly correlated with mean pulmonary artery pressure, pulmonary vascular resistance, and transpulmonary gradient (R coefficient=0.42, 0.27 and 0.32 respectively). Noninvasive estimation of pulmonary artery systolic pressure, acceleration time, and right ventricle-pulmonary artery coupling also correlated with wall thickness (R coefficient of 0.42, 0.27 and 0.49, respectively). Patients with a wall thickness over 0.25mm had significantly higher mean pulmonary pressures (37.00 vs 25.00mmHg; P=.004) and pulmonary vascular resistance (3.44 vs 2.08 WU; P=.017). CONCLUSIONS Direct morphological assessment of pulmonary vascular remodeling with OCT is feasible and is significantly associated with classic hemodynamic parameters. This weak association suggests that structural remodeling does not fully explain pulmonary hypertension.
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Affiliation(s)
- Jorge Martínez-Solano
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Carlos Ortiz-Bautista
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Enrique Gutiérrez-Ibañes
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - María Dolores García-Cosío
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Fernando Sarnago-Cebada
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Beatriz Díaz-Molina
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Isaac Pascual
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Manuel Gómez-Bueno
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Majadahonda, Spain
| | - Ramón Calviño-Santos
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servizo de Cardioloxía, Complexo Hospitalario Universitario A Coruña, Coruña, Spain
| | - Joan Antoni Gómez-Hospital
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servei de Cardiologia, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Juan García-Lara
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Luis de la Fuente-Galán
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Sonia Mirabet-Pérez
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servei de Cardiologia, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Ciencias Biomédicas y de la Salud, Universidad Europea, Madrid, Spain
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Duan Q, Zhang Y, Yang D. Perioperative fluid management for lung transplantation is challenging. Heliyon 2023; 9:e14704. [PMID: 37035359 PMCID: PMC10073756 DOI: 10.1016/j.heliyon.2023.e14704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/24/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
Lung transplantation is the definitive end-stage treatment for many lung diseases, and postoperative pulmonary oedema severely affects survival after lung transplantation. Optimizing perioperative fluid management can reduce the incidence of postoperative pulmonary oedema and improve the prognosis of lung transplant patients by removing the influence of patient, donor's lung and ECMO factors. Therefore, this article reviews seven aspects of lung transplant patients' pathophysiological characteristics, physiological characteristics of fluids, the influence of the donor lung on pulmonary oedema as well as current fluid rehydration concepts, advantages or disadvantages of intraoperative monitoring tools or types of fluids on postoperative pulmonary oedema, while showing the existing challenges in section 7. The aim is to show the specificity of perioperative fluid management in lung transplant patients and to provide new ideas for individualised fluid management in lung transplantation.
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Affiliation(s)
- Qirui Duan
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100144, China
| | - Yajun Zhang
- China-Japan Friendship Hospital, Beijing, 100020, China
- Corresponding author.
| | - Dong Yang
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100144, China
- Corresponding author.,
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23
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Affiliation(s)
- Brian A Houston
- From the Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston (B.A.H., R.J.T.); and the Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville (E.L.B.)
| | - Evan L Brittain
- From the Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston (B.A.H., R.J.T.); and the Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville (E.L.B.)
| | - Ryan J Tedford
- From the Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston (B.A.H., R.J.T.); and the Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville (E.L.B.)
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Randhawa VK, Spataru A, Jory L, Moussa F, Bhardwaj A, Rajapreyar I. Effects of Inhaled Pulmonary Vasodilators on Perioperative Right Ventricular Hemodynamics: Are These "Nebs" Simply Nebulous? Can J Cardiol 2023; 39:483-486. [PMID: 36746371 DOI: 10.1016/j.cjca.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Affiliation(s)
- Varinder K Randhawa
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Ana Spataru
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lindsay Jory
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Fuad Moussa
- Department of Cardiac Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anju Bhardwaj
- Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas/McGovern Medical School, Houston, Texas, USA
| | - Indranee Rajapreyar
- Division of Cardiology, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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25
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Bech-Hanssen O, Smith JG, Astengo M, Bollano E, Bobbio E, Polte CL, Bergh N, Karason K. Pulmonary Hypertension Phenotype Can Be Identified in Heart Failure With Reduced Ejection Fraction Using Echocardiographic Assessment of Pulmonary Artery Pressure With Supportive Use of Pressure Reflection Variables. J Am Soc Echocardiogr 2023:S0894-7317(23)00021-4. [PMID: 36681129 DOI: 10.1016/j.echo.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 01/10/2023] [Accepted: 01/10/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Pulmonary hypertension (PH) is frequent in patients with heart failure and reduced ejection fraction (HFrEF) with 2 different phenotypes: isolated postcapillary PH (IpcPH) and, with the worst prognosis, combined pre- and postcapillary PH (CpcPH). The aims of the present echocardiography study were to investigate (1) the ability to identify PH phenotype in patients with HFrEF using the newly adopted definition of PH (mean pulmonary artery pressure >20 mm Hg) and (2) the relationship between PH phenotype and right ventricular (RV) function. METHODS One hundred twenty-four patients with HFrEF consecutively referred for heart transplant or heart failure workup were included with echocardiography and right heart catheterization within 48 hours. We estimated systolic pulmonary artery pressure (sPAPDoppler) and used a method to detect increased pulmonary vascular resistance (>3 Wood units) based on predefined thresholds of 3 pressure reflection (PRefl) variables (the acceleration time in the RV outflow tract [RVOT], the interval between peak RVOT and peak tricuspid regurgitant velocity, and the RV pressure augmentation following peak RVOT velocity). RESULTS Using receiver operator characteristic analysis in a derivation group (n = 62), we identified sPAPDoppler ≥35 mm Hg as a cutoff that in a test group (n = 62) increased the likelihood of PH 6.6-fold. The presence of sPAPDoppler >40 mm Hg and 2 or 3 positive PRefl variables increased the probability of CpcPH 6- to 8-fold. A 2-step approach with primarily assessment of sPAPDoppler and the supportive use of PRefl variables in patients with mild/moderate PH (sPAPDoppler 41-59 mm Hg) showed 76% observer agreement and a weighted kappa of 0.63. The steady-state (pulmonary vascular resistance) and pulsatile (compliance, elastance) vascular loading are increased in both IpcPH and CpcPH with a comparable degree of RV dysfunction. CONCLUSIONS The PH phenotype can be identified in HFrEF using standard echocardiographic assessment of pulmonary artery pressure with supportive use of PRefl variables in patients with mild to moderate PH.
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Affiliation(s)
- Odd Bech-Hanssen
- Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenberg, Sweden.
| | - J Gustav Smith
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Wallenberg Laboratory and Department of Molecular and Clinical Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenberg, Sweden; Department of Cardiology, Clinical Sciences and Lund University and Skåne University Hospital, Lund, Sweden; Wallenberg Center for Molecular Medicine and Lund University Diabetes Center, Lund University and Skåne University Hospital, Lund, Sweden
| | - Marco Astengo
- Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenberg, Sweden
| | - Entela Bollano
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenberg, Sweden
| | - Emanuele Bobbio
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenberg, Sweden
| | - Christian Lars Polte
- Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenberg, Sweden
| | - Niklas Bergh
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenberg, Sweden
| | - Kristjan Karason
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Cardiology and Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenberg, Sweden
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Abstract
Patients with heart failure (HF) often have pulmonary hypertension (PH), which is mainly post-capillary; however, some of them also develop a pre-capillary component. The exact mechanisms leading to combined pre- and post-capillary PH are not yet clear, but the phenomenon seems to start from a passive transmission of increased pressure from the left heart to the lungs, and then continues with the remodeling of both the alveolar and vascular components through different pathways. More importantly, it is not yet clear which patients are predisposed to develop the disease. These patients have some characteristics similar to those with idiopathic pulmonary arterial hypertension (e.g., young age and frequent incidence in female gender), but they share cardiovascular risk factors with patients with HF (e.g., obesity and diabetes), with both reduced and preserved ejection fraction. Thanks to echocardiography parameters and newly introduced scores, more tools are available to distinguish between idiopathic pulmonary arterial hypertension and combined PH and to guide patients' management. It may be hypothesized to treat patients in whom the pre-capillary component is predominant with specific therapies such as those for idiopathic pulmonary arterial hypertension; however, no adequately powered trials of PH-specific treatment are available in combined PH. Early evidence of clinical benefit has been proven in some trials on phosphodiesterase type 5 inhibitors, while data on prostacyclin analogues, endothelin-1 receptor antagonists, and soluble guanylate cyclase stimulators are still controversial.
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27
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Karvasarski E, Bentley RF, Buchan TA, Valle FH, Wright SP, Chang IS, Granton JT, Mak S. Alterations of pulmonary vascular afterload in exercise-induced pre- and post-capillary pulmonary hypertension. Physiol Rep 2023; 11:e15559. [PMID: 36636024 PMCID: PMC9837421 DOI: 10.14814/phy2.15559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 06/17/2023] Open
Abstract
Exercise imposes increased pulmonary vascular afterload based on rises in pulmonary artery (PA) wedge pressure, declines in PA compliance, and resistance-compliance time. In health, afterload stress stabilizes during steady-state exercise. Our objective was to examine alterations of these exercise-associated stresses in states of pre- and post-capillary pulmonary hypertension (PH). PA hemodynamics were evaluated at rest, 2 and 7 min of steady-state exercise at moderate intensity in patients who exhibited Pre-capillary (n = 22) and post-capillary PH (n = 22). Patients with normal exercise hemodynamics (NOR-HD) (n = 32) were also studied. During exercise in all groups, PA wedge pressure increased at 2 min, with no further change at 7 min. In post-capillary PH and NOR-HD, increases in PA diastolic pressure and diastolic pressure gradient remained stable at 2 and 7 min of exercise, while in pre-capillary PH, both continued to increase at 7 min. The behavior of the diastolic pressure gradient was linearly related to the duration of resistance-compliance time at rest (r2 = 0.843) and exercise (r2 = 0.760). Exercise resistance-compliance time was longer in pre-capillary PH associated with larger increases in diastolic pressure gradient. Conversely, resistance-compliance time was shortest in post-capillary PH compared to pre-capillary PH and NOR-HD and associated with limited increases in exercise diastolic pressure gradient. During steady-state, modest-intensity exercise-specific patterns of pulmonary vascular afterload responses were observed in pre- and post-capillary PH relative to NOR-HD. Longer resistance-compliance time related to greater increases in PA diastolic pressure and diastolic pressure gradients in pre-capillary PH, while shorter resistance-compliance time appeared to limit these increases in post-capillary PH.
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Affiliation(s)
- Elizabeth Karvasarski
- Sinai Health/University Health NetworkTorontoOntarioCanada
- Institute of Medical Science, Faculty of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Robert F. Bentley
- Faculty of Kinesiology and Physical EducationUniversity of TorontoTorontoOntarioCanada
| | - Tayler A. Buchan
- University Health NetworkTorontoOntarioCanada
- Department of MedicineUniversity of TorontoTorontoOntarioCanada
| | | | - Stephen P. Wright
- Heart and Vascular InstituteUniversity of British ColumbiaKelownaBritish ColumbiaCanada
| | - Isaac S. Chang
- Sinai Health/University Health NetworkTorontoOntarioCanada
- Department of MedicineUniversity of TorontoTorontoOntarioCanada
| | - John T. Granton
- University Health NetworkTorontoOntarioCanada
- Department of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Susanna Mak
- Sinai Health/University Health NetworkTorontoOntarioCanada
- Institute of Medical Science, Faculty of MedicineUniversity of TorontoTorontoOntarioCanada
- University Health NetworkTorontoOntarioCanada
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28
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Interatrial Septal Devices for HFpEF: What We Learned from REDUCE LAP-HF. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022. [DOI: 10.1007/s11936-022-00975-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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29
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Martínez-Solano J, Gutiérrez-Ibañes E, Ortiz-Bautista C, García-Cosío MD, Sarnago-Cebada F, Díaz-Molina B, Pascual I, Oteo-Domínguez JF, Gómez-Bueno M, Calviño-Santos R, Crespo-Leiro MG, Gómez-Hospital JA, Díez-López C, García-Lara J, Garrido-Bravo IP, de la Fuente-Galán L, López-Díaz J, Mirabet-Pérez S, Martínez-Sellés M. Pulmonary Vascular Remodeling and Prognosis in Patients Evaluated for Heart Transplantation: Insights from the OCTOPUS-CHF Study. J Cardiovasc Dev Dis 2022; 9:jcdd9120439. [PMID: 36547436 PMCID: PMC9785366 DOI: 10.3390/jcdd9120439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE In patients with advanced heart failure, the intravascular optical coherence tomography (OCT) of subsegmental pulmonary artery measurements is correlated with right heart catheterization parameters. Our aim was to study the prognostic value of pulmonary OCT, right heart catheterization data, and the echocardiographic estimation of pulmonary pressure in patients studied for elective heart transplants. METHODS This research is an observational, prospective, multicenter study involving 90 adults with a one-year follow-up. RESULTS A total of 10 patients (11.1%) died due to worsening heart failure before heart transplantation, 50 underwent a heart transplant (55.6%), and 9 died in the first year after the transplant. The patients with and without events (mortality or heart failure-induced hospitalization) had similar data regarding echocardiography, right heart catheterization, and pulmonary OCT (with a median estimated pulmonary artery systolic pressure of 42.0 mmHg, interquartile range (IQR) of 30.3-50.0 vs. 47.0 mmHg, IQR 34.6-59.5 and p = 0.79, median pulmonary vascular resistance of 2.2 Wood units, IQR 1.3-3.7 vs. 2.0 Wood units, IQR 1.4-3.2 and p = 0.99, and a median pulmonary artery wall thickness of 0.2 ± 0.5 mm vs. 0.2 ± 0.6 mm and p = 0.87). CONCLUSION Pulmonary vascular remodeling (evaluated with echocardiography, right heart catheterization, and pulmonary OCT) was not associated with prognosis in a selected sample of adults evaluated for elective heart transplants. Pulmonary OCT is safe and feasible for the evaluation of these patients.
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Affiliation(s)
- Jorge Martínez-Solano
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), 28007 Madrid, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
| | - Enrique Gutiérrez-Ibañes
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), 28007 Madrid, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
| | - Carlos Ortiz-Bautista
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), 28007 Madrid, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
| | - María Dolores García-Cosío
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), 28041 Madrid, Spain
| | - Fernando Sarnago-Cebada
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), 28041 Madrid, Spain
| | - Beatriz Díaz-Molina
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | - Isaac Pascual
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | - Juan Francisco Oteo-Domínguez
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain
| | - Manuel Gómez-Bueno
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain
| | - Ramón Calviño-Santos
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servizo de Cardioloxía, Complexo Hospitalario Universitario A Coruña, 15006 A Coruña, Spain
| | - María G Crespo-Leiro
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servizo de Cardioloxía, Complexo Hospitalario Universitario A Coruña, 15006 A Coruña, Spain
| | - Joan Antoni Gómez-Hospital
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servei de Cardiologia, Hospital Universitari de Bellvitge, 08907 Barcelona, Spain
| | - Carles Díez-López
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servei de Cardiologia, Hospital Universitari de Bellvitge, 08907 Barcelona, Spain
| | - Juan García-Lara
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Iris P Garrido-Bravo
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Luis de la Fuente-Galán
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Javier López-Díaz
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Sonia Mirabet-Pérez
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servei de Cardiologia, Hospital Universitario de la Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), 28007 Madrid, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Facultad de Ciencias Biomédicas y de la Salud, Universidad Europea, 28670 Madrid, Spain
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30
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Martínez-Solano J, Ortiz-Bautista C, Gutiérrez-Ibañes E, García-Cosío MD, Sarnago-Cebada F, Díaz-Molina B, Pascual I, Gómez-Bueno M, Calviño-Santos R, Gómez-Hospital JA, García-Lara J, de la Fuente-Galán L, Mirabet-Pérez S, Martínez-Sellés M. Evaluación mediante OCT del remodelado vascular pulmonar en insuficiencia cardiaca avanzada. Estudio OCTOPUS-CHF. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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31
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Ronderos-Botero DM, Dileep A, Yapor L, Singhal R. Disruption of cardio-pulmonary coupling in myopathies: Pathophysiological and mechanistic characterization with special emphasis on nemaline myopathy. Front Cardiovasc Med 2022; 9:996567. [DOI: 10.3389/fcvm.2022.996567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 09/30/2022] [Indexed: 11/09/2022] Open
Abstract
The heart and lung are in continuous reciprocal interaction that creates a functional and anatomical reserve referred to as cardiopulmonary coupling (CPC). Disruption of CPC can occur due to various cardiac or pulmonary pathologies but also can occur in patients with myopathies. Nemaline myopathy (NM) is a skeletal muscle heterogeneous disorder due to contractile proteins' gene mutations that impact lung and cardiac mechanics and thus is expected to adversely affect CPC in a complex manner. We present a case of NM and we review the literature on cardiac and pulmonary effects of myopathy-related disruption of CPC.
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Earasi K, Mihaltses J, Kennedy JLW, Rao S, Holsten L, Mazimba S, Doyle A, Mihalek AD. Intensive ultrafiltration strategy restores kidney transplant candidacy for patients with echocardiographic evidence of pulmonary hypertension. Clin Transplant 2022; 36:e14799. [PMID: 36029145 PMCID: PMC10078392 DOI: 10.1111/ctr.14799] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/12/2022] [Accepted: 08/10/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Pulmonary hypertension (PH) is prevalent in those with end-stage kidney disease (ESKD) and poses a barrier to kidney transplant due to its association with poor outcomes. Studies examining these adverse outcomes are limited and often utilize echocardiographic measurements of pulmonary artery systolic pressure (PASP) instead of the gold standard right heart catheterization (RHC). We hypothesized that in ESKD patients deemed ineligible for kidney transplant because of an echocardiographic diagnosis of PH the predominant cause of PH is hypervolemia and is potentially reversible. METHODS We conducted a prospective study of 16 patients with ESKD who were denied transplant candidacy. Prior echocardiograms and RHCs were reviewed for confirmation of PH. Patients were admitted for daily sessions of ultrafiltration for volume removal and repeat RHCs were performed following intervention. RHC parameters and body weight were compared before and after intervention. Statistical analysis was performed using PRISM GraphPad software. A p-value <.05 was considered statistically significant. RESULTS Following intervention, the mean pulmonary artery pressure (mPAP) and pulmonary arterial wedge pressure decreased from 45.0 ± 3.06 to 29.1 ± 7.77 mmHg (p < .0001) and 22.2 ± 5.06 to 13.1 ± 7.25 mmHg (p = .003), respectively. The pulmonary vascular resistance decreased from 4.73 ± 1.99 to 4.28 ± 2.07 WU (p = .30). Eleven patients from the initial cohort underwent successful kidney transplantation post-intervention with 100% survival at 1-year. CONCLUSIONS In ESKD patients, diagnoses of PH made by echocardiography may be largely due to hypervolemia and may be optimized using an intensive ultrafiltration strategy to restore transplant candidacy.
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Affiliation(s)
- Kranthikiran Earasi
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - John Mihaltses
- Eastern Nephrology Associates, Wilmington, North Carolina, USA
| | | | - Swati Rao
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA.,Division of Nephrology, University of Virginia, Charlottesville, Virginia, USA
| | - Laura Holsten
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA.,Division of Nephrology, University of Virginia, Charlottesville, Virginia, USA
| | - Sula Mazimba
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA.,Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Alden Doyle
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA.,Division of Nephrology, University of Virginia, Charlottesville, Virginia, USA
| | - Andrew D Mihalek
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA.,Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, Virginia, USA
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Neder JA, Phillips DB, O'Donnell DE, Dempsey JA. Excess ventilation and exertional dyspnoea in heart failure and pulmonary hypertension. Eur Respir J 2022; 60:13993003.00144-2022. [PMID: 35618273 DOI: 10.1183/13993003.00144-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/05/2022] [Indexed: 01/11/2023]
Abstract
Increased ventilation relative to metabolic demands, indicating alveolar hyperventilation and/or increased physiological dead space (excess ventilation), is a key cause of exertional dyspnoea. Excess ventilation has assumed a prominent role in the functional assessment of patients with heart failure (HF) with reduced (HFrEF) or preserved (HFpEF) ejection fraction, pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). We herein provide the key pieces of information to the caring physician to 1) gain unique insights into the seeds of patients' shortness of breath and 2) develop a rationale for therapeutically lessening excess ventilation to mitigate this distressing symptom. Reduced bulk oxygen transfer induced by cardiac output limitation and/or right ventricle-pulmonary arterial uncoupling increase neurochemical afferent stimulation and (largely chemo-) receptor sensitivity, leading to alveolar hyperventilation in HFrEF, PAH and small-vessel, distal CTEPH. As such, interventions geared to improve central haemodynamics and/or reduce chemosensitivity have been particularly effective in lessening their excess ventilation. In contrast, 1) high filling pressures in HFpEF and 2) impaired lung perfusion leading to ventilation/perfusion mismatch in proximal CTEPH conspire to increase physiological dead space. Accordingly, 1) decreasing pulmonary capillary pressures and 2) mechanically unclogging larger pulmonary vessels (pulmonary endarterectomy and balloon pulmonary angioplasty) have been associated with larger decrements in excess ventilation. Exercise training has a strong beneficial effect across diseases. Addressing some major unanswered questions on the link of excess ventilation with exertional dyspnoea under the modulating influence of pharmacological and nonpharmacological interventions might prove instrumental to alleviate the devastating consequences of these prevalent diseases.
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Affiliation(s)
- J Alberto Neder
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Devin B Phillips
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Denis E O'Donnell
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Jerome A Dempsey
- John Rankin Laboratory of Pulmonary Medicine, Dept of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
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Rieth AJ, Rivinius R, Lühring T, Grün D, Keller T, Grinninger C, Schüttler D, Bara CL, Helmschrott M, Frey N, Sandhaus T, Schulze C, Kriechbaum S, Vietheer J, Sindermann J, Welp H, Lichtenberg A, Choi YH, Richter M, Tello K, Richter MJ, Hamm CW, Boeken U. Hemodynamic markers of pulmonary vasculopathy for prediction of early right heart failure and mortality after heart transplantation. J Heart Lung Transplant 2022; 42:512-521. [PMID: 36333208 DOI: 10.1016/j.healun.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/13/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Elevated pulmonary vascular resistance (PVR) is broadly accepted as an imminent risk factor for mortality after heart transplantation (HTx). However, no current HTx recipient risk score includes PVR or other hemodynamic parameters. This study examined the utility of various hemodynamic parameters for risk stratification in a contemporary HTx population. METHODS Patients from seven German HTx centers undergoing HTx between 2011 and 2015 were included retrospectively. Established risk factors and complete hemodynamic datasets before HTx were analyzed. Outcome measures were overall all-cause mortality, 12-month mortality, and right heart failure (RHF) after HTx. RESULTS The final analysis included 333 patients (28% female) with a median age of 54 (IQR 46-60) years. The median mean pulmonary artery pressure was 30 (IQR 23-38) mm Hg, transpulmonary gradient 8 (IQR 5-10) mm Hg, and PVR 2.1 (IQR 1.5-2.9) Wood units. Overall mortality was 35.7%, 12-month mortality was 23.7%, and the incidence of early RHF was 22.8%, which was significantly associated with overall mortality (log-rank HR 4.11, 95% CI 2.47-6.84; log-rank p < .0001). Pulmonary arterial elastance (Ea) was associated with overall mortality (HR 1.74, 95% CI 1.25-2.30; p < .001) independent of other non-hemodynamic risk factors. Ea values below a calculated cutoff represented a significantly reduced mortality risk (HR 0.38, 95% CI 0.19-0.76; p < .0001). PVR with the established cutoff of 3.0 WU was not significant. Ea was also significantly associated with 12-month mortality and RHF. CONCLUSIONS Ea showed a strong impact on post-transplant mortality and RHF and should become part of the routine hemodynamic evaluation in HTx candidates.
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Affiliation(s)
- Andreas J Rieth
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany.
| | - Rasmus Rivinius
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany, German Center for Cardiovascular Research (DZHK), Heidelberg/Mannheim, Germany
| | - Tom Lühring
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany
| | - Dimitri Grün
- Department of Cardiology, Justus Liebig University Giessen, Giessen, Germany
| | - Till Keller
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany; Department of Cardiology, Justus Liebig University Giessen, Giessen, Germany
| | - Carola Grinninger
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Dominik Schüttler
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Christoph L Bara
- Department of Cardiac, Thorax, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Matthias Helmschrott
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany, German Center for Cardiovascular Research (DZHK), Heidelberg/Mannheim, Germany
| | - Norbert Frey
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany, German Center for Cardiovascular Research (DZHK), Heidelberg/Mannheim, Germany
| | - Tim Sandhaus
- Department of Cardiac Surgery, University Hospital Jena, Jena, Germany
| | | | - Steffen Kriechbaum
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany
| | - Julia Vietheer
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany
| | - Jürgen Sindermann
- Department of Cardiology, Münster University Hospital, Münster, Germany; Department of Rehabilitation, Schüchtermann Clinic, Bad Rothenfelde, Germany
| | - Henryk Welp
- Department of Cardiac Surgery, Münster University Hospital, Münster, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Yeong-Hoon Choi
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Manfred Richter
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Khodr Tello
- Department of Internal Medicine, Justus Liebig University Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Manuel J Richter
- Department of Internal Medicine, Justus Liebig University Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany; Department of Pneumology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany; Department of Cardiology, Justus Liebig University Giessen, Giessen, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Düsseldorf University Hospital, Düsseldorf, Germany
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Hou J, Yuan Y, Chen P, Lu K, Tang Z, Liu Q, Xu W, Zheng D, Xiong S, Pei H. Pathological Roles of Oxidative Stress in Cardiac Microvascular Injury. Curr Probl Cardiol 2022; 48:101399. [PMID: 36103941 DOI: 10.1016/j.cpcardiol.2022.101399] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 01/06/2023]
Abstract
Cardiac microvascular injury can be a fundamental pathological process that causes high incidence cardiovascular diseases such heart failure, diabetic cardiomyopathy, and hypertension. It is also an independent risk factor for cardiovascular disease. Oxidative stress is a significant pathological process in which the body interferes with the balance of the endogenous antioxidant defense system by producing reactive oxygen species, leading to property changes and dysfunction. It has been demonstrated that oxidative stress is one of the major causes of cardiac microvascular disease. Therefore, additional investigation into the relationship between oxidative stress and cardiac microvascular injury will direct clinical management in the future. In order to give suggestions and support for future in-depth studies, we give a basic overview of the cardiac microvasculature in relation to physiopathology in this review. We also summarize the role of oxidative stress of mitochondrial and non-mitochondrial origin in cardiac microvascular injury and related drug studies.
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Affiliation(s)
- Jun Hou
- Department of Cardiology, Chengdu Third People's Hospital/Affiliated Hospital of Southwest Jiao Tong University, Chengdu 610031, China
| | - Yuan Yuan
- Department of Pharmacy, The General Hospital of Western Theater Command, Chengdu 610083, China
| | - Peiwen Chen
- School of Medical and Life Sciences, Chengdu University of TCM, Chengdu 611130, China
| | - Keji Lu
- School of Medical and Life Sciences, Chengdu University of TCM, Chengdu 611130, China
| | - Zhaobing Tang
- Department of Rehabilitation Medicine, The General Hospital of Western Theater Command, Chengdu 610083, China
| | - Qing Liu
- Department of medical engineering, The 950th Hospital of PLA, Yecheng 844900, China
| | - Wu Xu
- Department of Urology, The Fifth Afliated Hospital of Southern Medical University, Guangzhou 510900, China
| | - Dezhi Zheng
- Department of Cardiovascular Surgery, the 960th Hospital of the PLA Joint Logistic Support Force, Jinan 250031, China
| | - Shiqiang Xiong
- Department of Cardiology, Chengdu Third People's Hospital/Affiliated Hospital of Southwest Jiao Tong University, Chengdu 610031, China
| | - Haifeng Pei
- Department of Cardiology, The General Hospital of Western Theater Command, Chengdu 610083, China.
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Stencel J, Rajapreyar I, Samson R, Le Jemtel T. Comprehensive and Safe Decongestion in Acutely Decompensated Heart Failure. Curr Heart Fail Rep 2022; 19:364-374. [PMID: 36045314 DOI: 10.1007/s11897-022-00573-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF THE REVIEW Progressive intravascular, interstitial, and alveolar fluid overload underlies the transition from compensated to acutely decompensated heart failure and loop diuretics are the mainstay of treatment. Adverse effects and resistance to loop diuretics received much attention while the contribution of a depressed cardiac output to diuretic resistance was downplayed. RECENT FINDINGS Analysis of experience with positive inotropic agents, especially dobutamine, indicates that enhancement of cardiac output is not consistently associated with increased renal blood flow. However, urinary output and renal sodium excretion increase likely due to dobutamine-mediated decrease in renal and systemic reduced activation of sympathetic nervous- and renin-angiotensin-aldosterone system. Mechanical circulatory support with left ventricular assist devices ascertained the contribution of low cardiac output to diuretic resistance and the pathogenesis and progression of kidney disease in acutely decompensated heart failure. Diuretic resistance commonly occurs in acutely decompensated heart failure. However, failure to resolve fluid overload despite high doses of loop diuretics should alert to the presence of a low cardiac output state.
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Affiliation(s)
- Jason Stencel
- Tulane University School of Medicine, New Orleans, LA, USA.
| | | | - Rohan Samson
- Rudd Heart and Lung Center, University of Louisville Health, Louisville, KY, USA
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Bowcock EM, Mclean A. Bedside assessment of left atrial pressure in critical care: a multifaceted gem. Crit Care 2022; 26:247. [PMID: 35964098 PMCID: PMC9375940 DOI: 10.1186/s13054-022-04115-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/31/2022] [Indexed: 11/23/2022] Open
Abstract
Evaluating left atrial pressure (LAP) solely from the left ventricular preload perspective is a restrained approach. Accurate assessment of LAP is particularly relevant when pulmonary congestion and/or right heart dysfunction are present since it is the pressure most closely related to pulmonary venous pressure and thus pulmonary haemodynamic load. Amalgamation of LAP measurement into assessment of the ‘transpulmonary circuit’ may have a particular role in differentiating cardiac failure phenotypes in critical care. Most of the literature in this area involves cardiology patients, and gaps of knowledge in application to the bedside of the critically ill patient remain significant. Explored in this review is an overview of left atrial physiology, invasive and non-invasive methods of LAP measurement and their potential clinical application.
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38
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Reiter G, Kovacs G, Reiter C, Schmidt A, Fuchsjäger M, Olschewski H, Reiter U. Left atrial acceleration factor as a magnetic resonance 4D flow measure of mean pulmonary artery wedge pressure in pulmonary hypertension. Front Cardiovasc Med 2022; 9:972142. [PMID: 35990987 PMCID: PMC9381926 DOI: 10.3389/fcvm.2022.972142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 07/11/2022] [Indexed: 12/04/2022] Open
Abstract
Background Mean pulmonary artery wedge pressure (PAWP) represents a right heart catheter (RHC) surrogate measure for mean left atrial (LA) pressure and is crucial for the clinical classification of pulmonary hypertension (PH). Hypothesizing that PAWP is related to acceleration of blood throughout the LA, we investigated whether an adequately introduced LA acceleration factor derived from magnetic resonance (MR) four-dimensional (4D) flow imaging could provide an estimate of PAWP in patients with known or suspected PH. Methods LA 4D flow data of 62 patients with known or suspected PH who underwent RHC and near-term 1.5 T cardiac MR (ClinicalTrials.gov identifier: NCT00575692) were retrospectively analyzed. Early diastolic LA peak outflow velocity (vE) as well as systolic (vS) and early diastolic (vD) LA peak inflow velocities were determined with prototype software to calculate the LA acceleration factor (α) defined as α = vE/[(vS + vD)/2]. Correlation, regression and Bland-Altman analysis were employed to investigate the relationship between α and PAWP, α-based diagnosis of elevated PAWP (>15 mmHg) was analyzed by receiver operating characteristic curve analysis. Results α correlated very strongly with PAWP (r = 0.94). Standard deviation of differences between RHC-derived PAWP and PAWP estimated from linear regression model (α = 0.61 + 0.10·PAWP) was 2.0 mmHg. Employing the linear-regression-derived cut-off α = 2.10, the α-based diagnosis of elevated PAWP revealed the area under the curve 0.97 with sensitivity/specificity 93%/92%. Conclusions The very close relationship between the LA acceleration factor α and RHC-derived PAWP suggests α as potential non-invasive parameter for the estimation of PAWP and the distinction between pre- and post-capillary PH.
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Affiliation(s)
- Gert Reiter
- Research & Development, Siemens Healthcare Diagnostics GmbH, Graz, Austria
- Division of General Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Gabor Kovacs
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research Graz, Austria
| | - Clemens Reiter
- Division of General Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Albrecht Schmidt
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Michael Fuchsjäger
- Division of General Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Horst Olschewski
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research Graz, Austria
| | - Ursula Reiter
- Division of General Radiology, Department of Radiology, Medical University of Graz, Austria
- *Correspondence: Ursula Reiter
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van der Bijl P, Bax JJ. Using deep learning to diagnose pulmonary hypertension. Eur Heart J Cardiovasc Imaging 2022; 23:1457-1458. [PMID: 35906842 DOI: 10.1093/ehjci/jeac148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Pieter van der Bijl
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.,Heart Centre, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, FI-20520, Turku, Finland
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40
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Johnson SW, Finlay L, Mathai SC, Goldstein RH, Maron BA. Real-world use of inhaled treprostinil for lung disease-pulmonary hypertension: A protocol for patient evaluation and prescribing. Pulm Circ 2022; 12:e12126. [PMID: 36092795 PMCID: PMC9450844 DOI: 10.1002/pul2.12126] [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: 06/08/2022] [Revised: 07/18/2022] [Accepted: 08/09/2022] [Indexed: 11/08/2022] Open
Abstract
Inhaled treprostinil was approved recently for interstitial lung disease-pulmonary hypertension; however, efficacy in "real-world" populations is not known. We designed a protocol and report our experience evaluating 10 patients referred for therapy. Misdiagnosis at presentation was common; ultimately, three patients (30%) were prescribed drug. This protocol offers an opportunity to standardize longitudinal assessment of inhaled treprostinil in clinical practice.
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Affiliation(s)
- Shelsey W. Johnson
- Department of Pulmonary, Allergy, Sleep, and Critical Care Medicine, VA Boston Healthcare SystemBostonMassachusettsUSA,The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical CareBoston University School of MedicineBostonMassachusettsUSA
| | - Lauren Finlay
- Department of PharmacyVA Boston Healthcare SystemBostonMassachusettsUSA
| | - Stephen C. Mathai
- Department of Pulmonary and Critical Care MedicineJohns Hopkins University, and Johns Hopkins School of MedicineBaltimoreMarylandUSA
| | - Ronald H. Goldstein
- Department of Pulmonary, Allergy, Sleep, and Critical Care Medicine, VA Boston Healthcare SystemBostonMassachusettsUSA,The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical CareBoston University School of MedicineBostonMassachusettsUSA
| | - Bradley A. Maron
- Department of Pulmonary, Allergy, Sleep, and Critical Care Medicine, VA Boston Healthcare SystemBostonMassachusettsUSA,Division of Cardiovascular MedicineBrigham and Women's Hospital, and Harvard Medical SchoolBostonMassachusettsUSA
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41
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Mak S, Kolker S, Girdharry NR, Bentley RF, Valle FH, Gurtu V, Mok KH, Moric J, Thenganatt J, Granton JT. THE ROLE OF EXERCISE RIGHT HEART CATHETERIZATION TO GUIDE PULMONARY HYPERTENSION THERAPY IN OLDER ADULTS. Pulm Circ 2022; 12:e12103. [PMID: 35911185 PMCID: PMC9329818 DOI: 10.1002/pul2.12103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/26/2022] [Accepted: 06/10/2022] [Indexed: 11/26/2022] Open
Abstract
The spectrum of patients referred for suspected pulmonary arterial hypertension (PAH) includes a population with clinical features suggestive of pulmonary hypertension due to left heart disease (PH‐LHD). Even after right heart catheterization (RHC) performed at rest, it can be a challenge to identify patients who will clearly benefit from PAH drug therapy. Therefore, the objective of this study was to evaluate the role of exercise RHC to influence decisions regarding prescription of PAH drug therapy in this population. A retrospective cohort study was conducted of older adults with risk factors for PH‐LHD and suspected PH referred for exercise RHC. One year follow‐up was conducted to record clinical outcomes, all changes in PAH drug therapy, and changes in patient‐reported quality of life. The final cohort included 61 patients, mean age of 69 ± 10; 44% and 34% had a history of coronary artery disease and atrial fibrillation respectively. Exercise changed the proportional breakdown of hemodynamic diagnoses from 36% No PH, 44% PAH, and 20% PH‐LHD at rest to 15% No PH, 36% PAH, and 49% PH‐LHD. Although a significant proportion of patients were reclassified as PH‐LHD, there was an overall increase in the proportion of patients receiving PAH drug therapy, particularly for those with PAH confirmed by exercise RHC. A total of 11 PAH drug prescriptions were employed before exercise RHC increasing to 24 after (p = 0.002). Patients receiving PAH therapy demonstrated significant improvement in self‐reported quality of life. Exercise RHC appeared to influence selection of PAH drug therapy.
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Affiliation(s)
- Susanna Mak
- Sinai Health/University Health Network, Department of Medicine, University of Toronto
| | | | - Natasha R. Girdharry
- Sinai Health/University Health Network, Department of Medicine, University of Toronto
| | | | | | - Vikram Gurtu
- Sinai Health/University Health Network, Department of Medicine, University of Toronto
| | - K. H. Mok
- Sinai Health/University Health Network, Department of Medicine, University of Toronto
| | - Jakov Moric
- Sinai Health/University Health Network, Department of Medicine, University of Toronto
| | - John Thenganatt
- Sinai Health/University Health Network, Department of Medicine, University of Toronto
| | - John T Granton
- Sinai Health/University Health Network, Department of Medicine, University of Toronto
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Affiliation(s)
- Simone L Savaris
- Division of Cardiology, Mount Sinai Hospital, Toronto, ON, Canada (S.L.S., S.M.)
| | | | - Stephen P Wright
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, Canada (S.P.W.)
| | - Susanna Mak
- Division of Cardiology, Mount Sinai Hospital, Toronto, ON, Canada (S.L.S., S.M.)
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43
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Liu QQ, Yang J, Lu D, Xu XQ, Jiang X, Wang H, Li JY, Guo F, Zhu YL, Zhao QH. Time-Velocity Integral of Left Ventricular Outflow Tract Predicts Worse Long-Term Survival in Pulmonary Arterial Hypertension. JACC. ASIA 2022; 2:235-243. [PMID: 36338398 PMCID: PMC9627844 DOI: 10.1016/j.jacasi.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The time-velocity integral of the left ventricular outflow tract (TVILVOT) has been demonstrated to correlate with heart failure hospitalization and mortality, but the association of TVILVOT with the severity and prognosis of pulmonary arterial hypertension (PAH) has not been evaluated. OBJECTIVES The aim of this study was to investigate the predictive value of baseline TVILVOT in PAH. METHODS A total of 225 consecutive patients with a diagnosis of incident PAH were prospectively studied and echocardiology-derived TVILVOT was measured at enrollment followed by right heart catheterization examination within 48 hours. Cox proportional hazards analysis was performed to assess the association between baseline variables and mortality. RESULTS During a median follow-up period of 33.8 months, 44 patients died of cardiovascular events. Baseline TVILVOT was significantly lower in the nonsurvivors compared with the survivors (P < 0.001). Baseline TVILVOT was positively correlated with stroke volume obtained by right heart catheterization (r = 0.709; P < 0.001), and inversely correlated with N-terminal pro-B-type natriuretic peptide (r = -0.533; P < 0.001), pulmonary vascular resistance (r = -0.423; P < 0.001). Multivariate analysis showed that baseline TVILVOT (hazard ratio: 0.856; 95% CI: 0.780-0.941; P = 0.001) was an independent predictor of cardiovascular mortality in PAH. Patients with a baseline TVILVOT <17.1 cm (median value) had a significantly worse survival than those with a baseline TVILVOT ≥17.1 cm (P < 0.001). CONCLUSIONS The findings of this study suggest that noninvasive TVILVOT provides a practical method to assess the severity and predict long-term outcome of PAH.
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Key Words
- 6MWD, 6-minute walk distance
- BSA, body surface area
- CI, cardiac index
- CMR, cardiac magnetic resonance imaging
- CO, cardiac output
- HR, hazard ratio
- LV, left ventricular
- LVOT, left ventricular outflow tract
- NT-proBNP, N-terminal pro–B-type natriuretic peptide
- PAH, pulmonary arterial hypertension
- PVR, pulmonary vascular resistance
- RHC, right heart catheterization
- RV, right ventricular
- STr, peak systolic tricuspid annular velocity of tissue Doppler
- SVRHC, stroke volume obtained by right heart catheterization
- TAPSE, tricuspid annular plane systolic excursion
- TTE, transthoracic echocardiography
- TVI, time-velocity integral
- TVILVOT, time-velocity integral of left ventricular outflow tract
- WHO-FC, World Health Organization functional class
- left ventricular outflow tract
- pulmonary arterial hypertension
- survival
- time-velocity integral
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Affiliation(s)
- Qian-Qian Liu
- Department of Echocardiography, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Yang
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dan Lu
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Qi Xu
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Jiang
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Wang
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing-Yi Li
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fan Guo
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan-Lin Zhu
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qin-Hua Zhao
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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Yu W, Dujiang X, Yi W, Guanwen D, Mengyu Z, Chang P, Aikai Z, Juan Z, Linlin Z, Hang Z. Apolipoprotein A1 Is Associated with Pulmonary Vascular Resistance and Adverse Clinical Outcomes in Patients with Pulmonary hypertension secondary to Heart Failure. Pulm Circ 2022; 12:e12096. [PMID: 35911182 PMCID: PMC9326519 DOI: 10.1002/pul2.12096] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 04/19/2022] [Accepted: 05/06/2022] [Indexed: 11/21/2022] Open
Abstract
Pulmonary hypertension secondary to heart failure (HF‐PH) combined with pulmonary vascular remodeling has a high mortality rate. Apolipoprotein A1 (ApoA1) has been shown to adversely affect outcomes in patients with HF. A prospective follow‐up study was performed on 239 consecutive patients with HF‐PH who underwent right heart catheterization. Proteomics technology was used to analyze different proteins in plasma between post‐ and precapillary pulmonary hypertension (CpcPH) and isolated postcapillary pulmonary hypertension (IpcPH) filtered by propensity score matching. Ultimately, 175 patients were enrolled and followed for an average of 4.4 years. Lipoprotein components in plasma were measured, and the following clinical events were tracked. Proteomics data showed that lipid metabolism and inflammation were different between CpcPH and IpcPH. ApoA1 levels in HF‐PH patients with CpcPH were lower than those in HF‐PH patients with IpcPH. The patients with lower ApoA1 levels (≤1.025 g/L) were in a higher New York Heart Association class and had high levels of NT‐proBNP, mean pulmonary artery pressure, PVR, and diastolic pressure gradient. Besides, HF‐PH patients with lower ApoA1 levels had a 2.836‐fold higher relative risk of comorbid CpcPH compared with patients with higher ApoA1 levels. Moreover, patients with lower ApoA1 levels had a lower survival rate after adjusting for CpcPH. In conclusion, ApoA1 levels were negatively correlated with PVR levels. Lower ApoA1 levels were an independent risk factor for pulmonary vascular remodeling in HF‐PH patients. The survival of HF‐PH patients with lower ApoA1 levels was reduced.
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Affiliation(s)
- Wande Yu
- Division of Cardiology, Nanjing First Hospital Nanjing Medical University Nanjing China
| | - Xie Dujiang
- Division of Cardiology, Nanjing First Hospital Nanjing Medical University Nanjing China
| | - Wang Yi
- 2rd College Nanjing Medical University Nanjing China
| | | | - Zhang Mengyu
- 2rd College Nanjing Medical University Nanjing China
| | - Pan Chang
- Division of Cardiology, Nanjing First Hospital Nanjing Medical University Nanjing China
| | - Zhang Aikai
- 2rd College Nanjing Medical University Nanjing China
| | - Zhang Juan
- Division of Cardiology, Nanjing First Hospital Nanjing Medical University Nanjing China
| | - Zhu Linlin
- Division of Cardiology, Nanjing First Hospital Nanjing Medical University Nanjing China
| | - Zhang Hang
- Division of Cardiology, Nanjing First Hospital Nanjing Medical University Nanjing China
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45
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Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Cardiology, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts
| | - Marc Humbert
- Université Paris-Saclay, INSERM, Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin Bicêtre, France
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46
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Yang JH, Harada T, Choi KH, Kato T, Kim D, Takama N, Park TK, Kurabayashi M, Chang SA, Obokata M. Peripheral Venous Pressure-Assisted Exercise Stress Echocardiography in the Evaluation of Pulmonary Hypertension During Exercise in Patients With Suspected Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2022; 15:e009028. [PMID: 35189688 DOI: 10.1161/circheartfailure.121.009028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Identification of elevated pulmonary artery (PA) pressures during exercise may provide diagnostic, prognostic, and therapeutic implications in heart failure with preserved ejection fraction. Although widely performed, exercise stress echocardiography may underestimate true PA pressures due to the difficulty in estimating right atrial pressure (RAP) during exercise. We hypothesized that peripheral venous pressure (PVP) could allow for reliable estimation of RAP, and thus PA pressures during exercise stress echocardiography. METHODS In protocol 1, we investigated the accuracy of PVP compared with simultaneously measured RAP at rest and during exercise right heart catheterization in 19 subjects. In protocol 2, we examined whether the addition of PVP to Doppler exercise echocardiography (tricuspid regurgitant velocity) would increase the ability to identify exercise-induced pulmonary hypertension compared with inferior vena cava-based RAP estimation in 60 patients with dyspnea. RESULTS In protocol 1, PVP was strongly correlated with simultaneously measured RAP at rest and during exercise (r=0.77 and 0.90), with little overestimation of invasively measured RAP (bias 3.4 mm Hg at rest and 1.7 mm Hg during exercise). In protocol 2, PVP increased dramatically during exercise echocardiography (14±5 mm Hg) while an increase in inferior vena cava-based RAP was modest (6±4 mm Hg). Exercise PA pressures calculated from PVP and tricuspid regurgitant velocity were significantly higher than those estimated from inferior vena cava and the use of PVP increased the proportion of patients with exercise-induced pulmonary hypertension from 40% to 68%. CONCLUSIONS PVP may prevent underestimation of PA pressures during exercise echocardiography and could be a preferred approach to identify exercise-induced pulmonary hypertension in patients with suspected heart failure with preserved ejection fraction.
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Affiliation(s)
- Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.(J.H.Y.).,Department of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. (J.H.Y., K.H.C., D.K., T.K.P., S.-A.C.)
| | - Tomonari Harada
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan (T.H., T.K., N.T., M.K., M.O.)
| | - Ki Hong Choi
- Department of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. (J.H.Y., K.H.C., D.K., T.K.P., S.-A.C.)
| | - Toshimitsu Kato
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan (T.H., T.K., N.T., M.K., M.O.)
| | - Darae Kim
- Department of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. (J.H.Y., K.H.C., D.K., T.K.P., S.-A.C.)
| | - Noriaki Takama
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan (T.H., T.K., N.T., M.K., M.O.)
| | - Taek Kyu Park
- Department of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. (J.H.Y., K.H.C., D.K., T.K.P., S.-A.C.)
| | - Masahiko Kurabayashi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan (T.H., T.K., N.T., M.K., M.O.)
| | - Sung-A Chang
- Department of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. (J.H.Y., K.H.C., D.K., T.K.P., S.-A.C.)
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan (T.H., T.K., N.T., M.K., M.O.)
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47
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Johnson SW, Maron BA. COUNTERPOINT: Did the World Symposium on Pulmonary Hypertension Get It Right in Redefining Abnormal Pulmonary Arterial Pressure? No. Chest 2022; 161:313-315. [DOI: 10.1016/j.chest.2021.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/11/2021] [Indexed: 10/19/2022] Open
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48
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D'Alto M, Di Maio M, Romeo E, Argiento P, Blasi E, Di Vilio A, Rea G, D'Andrea A, Golino P, Naeije R. Echocardiographic probability of pulmonary hypertension: a validation study. Eur Respir J 2022; 60:13993003.02548-2021. [PMID: 34996833 DOI: 10.1183/13993003.02548-2021] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/10/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND According to current guidelines, the diagnosis of pulmonary hypertension (PH) relies on echocardiographic probability followed by right heart catheterization. How echocardiography predicts PH recently re-defined by a mean pulmonary artery pressure (mPAP) >20 mmHg instead of ≥25 mmHg and pulmonary vascular disease defined by a pulmonary vascular resistance (PVR) >3 or >2 Wood units has not been established. METHODS A total of 278 patients referred for PH underwent a comprehensive echocardiography followed by a right heart catheterization. Fifteen patients (5.4%) were excluded because of insufficient quality echocardiography. RESULTS With PH defined by a mPAP >20 mmHg, 23 patients had no PH, 146 had pre-capillary and 94 post-capillary PH. At univariate analysis, maximum velocity of tricuspid regurgitation (TRV) ≥2.9 and ≤3.4 m s-1, left ventricle (LV) eccentricity index >1.1, right ventricle (RV) outflow tract (OT) notching or acceleration time <105 ms, RV-LV basal diameter >1 and PA diameter predicted PH, whereas inferior vena cava diameter and right atrial area did not. At multivariable analysis, only TRV ≥2.9 m s-1 independently predicted PH. Additional independent prediction of PVR >3 Wood units was offered by LV eccentricity index >1.1 and RVOT acceleration time <105 ms and/or notching, but with no improvement of optimal combination of specificity and sensibility or positive prediction. CONCLUSIONS Echocardiography as recommended in current guidelines can be used to assess the probability of re-defined PH in a referral center. However, the added value of indirect signs is modest and sufficient quality echocardiographic signals may not be recovered in some patients.
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Affiliation(s)
- Michele D'Alto
- Department of Cardiology, University "L. Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Marco Di Maio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (Salerno), Italy
| | - Emanuele Romeo
- Department of Cardiology, University "L. Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Paola Argiento
- Department of Cardiology, University "L. Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Ettore Blasi
- Department of Cardiology, University "L. Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Alessandro Di Vilio
- Department of Cardiology, University "L. Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Gaetano Rea
- Radiology Unit, Monaldi Hospital, Naples, Italy
| | - Antonello D'Andrea
- Unit of Cardiology and Intensive Coronary Care, "Umberto I" Hospital, Nocera Inferiore, Italy
| | - Paolo Golino
- Department of Cardiology, University "L. Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Robert Naeije
- Department of Pathophysiology, Free University of Brussels, Brussels, Belgium
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49
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Maron BA, Choudhary G, Goldstein RL, Garshick E, Jankowich M, Tucker TJS, LaCerda KA, Hattler B, Dempsey EC, Sadikot RT, Shapiro S, Rounds SI, Goldstein RH. Tadalafil for veterans with chronic obstructive pulmonary disease-pulmonary hypertension: A multicenter, placebo-controlled randomized trial. Pulm Circ 2022; 12:e12043. [PMID: 35506072 PMCID: PMC9053004 DOI: 10.1002/pul2.12043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 11/11/2022] Open
Abstract
Treating Veterans with chronic obstructive pulmonary disease complicated by pulmonary hypertension (COPD-PH) using phosphodiesterase type-5 inhibitor pharmacotherapy is common, but efficacy data are lacking. To address this further, patients with COPD-PH from five Department of Veterans Affairs hospitals were randomized (1∶1) to receive placebo or oral tadalafil (40 mg/day) for 12 months. The primary endpoint was changed from baseline in 6-min walk distance at 12 months. Secondary endpoints included change from baseline in pulmonary vascular resistance, mean pulmonary artery pressure, and symptom burden by the University of California San Diego shortness of breath questionnaire scale at 6 months. A total of 42 subjects (all male; 68 ± 7.6 years old) were randomized to placebo (N = 14) or tadalafil (N = 28). The group imbalance was related to under-enrollment. Compared to placebo, no significant difference was observed in the tadalafil group for change from the primary endpoint or change in mean pulmonary artery pressure or pulmonary vascular resistance from baseline at 6 months. A clinically meaningful improvement was observed in the secondary endpoint of shortness of breath questionnaire score in the tadalafil versus placebo group at 6 months. There was no significant difference in major adverse events between treatment groups, and tadalafil was well tolerated overall. For Veterans with COPD-PH enrolled in this study, once-daily treatment with tadalafil did not improve 6-min walk distance or cardiopulmonary hemodynamics although a decrease in shortness of breath was observed. Under-enrollment and imbalanced randomization confound interpreting conclusions from this clinical trial and limit the generalization of our findings.
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Affiliation(s)
- Bradley A. Maron
- Department of Medicine, Section of Cardiology and Division of Pulmonary, Allergy, Sleep, and Critical Care MedicineVeterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
- Division of Cardiovascular MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Gaurav Choudhary
- Department of MedicineProvidence Veterans Affairs Medical CenterProvidenceRhode IslandUSA
- Department of MedicineAlpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Rebekah L. Goldstein
- Research and Development ServiceVeterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
| | - Eric Garshick
- Department of Medicine, Research and Development Service, Pulmonary, Allergy, Sleep, and Critical Care Medicine SectionVeterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
- Channing Division of Network MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Matthew Jankowich
- Department of MedicineProvidence Veterans Affairs Medical CenterProvidenceRhode IslandUSA
- Department of MedicineAlpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Troo J. S. Tucker
- Department of MedicineProvidence Veterans Affairs Medical CenterProvidenceRhode IslandUSA
| | - Kathleen A. LaCerda
- Department of Medicine, Research and Development Service, Pulmonary, Allergy, Sleep, and Critical Care Medicine SectionVeterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
| | - Brack Hattler
- Cardiology SectionRocky Mountain Regional Veterans Affairs Medical CenterAuroraColoradoUSA
| | - Edward C. Dempsey
- Cardiology SectionRocky Mountain Regional Veterans Affairs Medical CenterAuroraColoradoUSA
- Pulmonary Sciences and Critical Care Medicine SectionUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Ruxana T. Sadikot
- Department of MedicineAtlanta Veterans Affairs Medical CenterDecaturGeorgiaUSA
| | - Shelley Shapiro
- Department of Cardiology, Cardiology Section Greater Los AngelesVA Healthcare SystemLos AngelesCaliforniaUSA
- Division of Pulmonary Critical CareDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
| | - Sharon I. Rounds
- Department of MedicineProvidence Veterans Affairs Medical CenterProvidenceRhode IslandUSA
- Department of MedicineAlpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Ronald H. Goldstein
- Department of Medicine, Research and Development Service, Pulmonary, Allergy, Sleep, and Critical Care Medicine SectionVeterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
- Department of MedicineBoston University School of MedicineBostonMassachusettsUSA
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50
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Izumo M. Value of Echocardiography in the Treatment of Patients With Acute Heart Failure. Front Cardiovasc Med 2021; 8:740439. [PMID: 34869645 PMCID: PMC8634439 DOI: 10.3389/fcvm.2021.740439] [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: 07/13/2021] [Accepted: 09/14/2021] [Indexed: 11/25/2022] Open
Abstract
Heart failure (HF) is a burden in pandemic medicine resulting in high mortality and morbidity. Because acute HF is a life-threatening event, its diagnosis and choice of optimal treatment are important to improve outcomes. Furthermore, understanding the cause and hemodynamics of acute HF is important in selecting the optimal treatment for these patients. Echocardiography is widely used in daily clinical practice because of its non-invasive nature and excellent portability to understand cardiac function and hemodynamics. Echocardiography is highly recommended by guidelines in the practice of HF, but evidence is limited. In this review, I would like to share clinical value of echocardiography in the treatment of patients with acute HF and discuss the usefulness of echocardiography.
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Affiliation(s)
- Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
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