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Madonna R, Biondi F, Ghelardoni S, D'Alleva A, Quarta S, Massaro M. Pulmonary hypertension associated to left heart disease: Phenotypes and treatment. Eur J Intern Med 2024:S0953-6205(24)00326-1. [PMID: 39095300 DOI: 10.1016/j.ejim.2024.07.030] [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: 02/05/2024] [Revised: 06/19/2024] [Accepted: 07/20/2024] [Indexed: 08/04/2024]
Abstract
Pulmonary hypertension associated to left heart disease (PH-LHD) refers to a clinical and haemodynamic condition of pulmonary hypertension associated with a heterogeneous group of diseases affecting any of the compartments that form the left ventricle and left atrium. PH-LHD is the most common cause of PH, accounting for 65-80 % of diagnoses. Based on the haemodynamic phase of the disease, PH-LDH is classified into three subgroups: postcapillary PH, isolated postcapillary PH and combined pre-postcapillary PH (CpcPH). Several signaling pathways involved in the regulation of vascular tone are dysfunctional in PH-LHD, including nitric oxide, MAP kinase and endothelin-1 pathways. These pathways are the same as those altered in PH group 1, however PH-LHD can heardly be treated by specific drugs that act on the pulmonary circulation. In this manuscript we provide a state of the art of the available clinical trials investigating the safety and efficacy of PAH-specific drugs, as well as drugs active in patients with heart failure and PH-LHD. We also discuss the different phenotypes of PH-LHD, as well as molecular targets and signaling pathways potentially involved in the pathophysiology of the disease. Finally we will mention some new emerging therapies that can be used to treat this form of PH.
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Affiliation(s)
- Rosalinda Madonna
- University Cardiology Division, Pisa University Hospital and University of Pisa, Via Paradisa, 2, Pisa 56124, Italy.
| | - Filippo Biondi
- University Cardiology Division, Pisa University Hospital and University of Pisa, Via Paradisa, 2, Pisa 56124, Italy
| | - Sandra Ghelardoni
- Department of Pathology, Laboratory of Biochemistry, University of Pisa, Italy
| | - Alberto D'Alleva
- Cardiac Intensive Care and Interventional Cardiology Unit, Santo Spirito Hospital, Pescara, Italy
| | - Stefano Quarta
- Institute of Clinical Physiology (IFC), National Research Council (CNR), Lecce 73100, Italy
| | - Marika Massaro
- Institute of Clinical Physiology (IFC), National Research Council (CNR), Lecce 73100, Italy
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Pasledni R, Kozarski M, Mizerski JK, Darowski M, Okrzeja P, Zieliński K. The hybrid (physical-computational) cardiovascular simulator to study valvular diseases. J Biomech 2024; 170:112173. [PMID: 38805856 DOI: 10.1016/j.jbiomech.2024.112173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 05/30/2024]
Abstract
To better understand the impact of valvular heart disease (VHD) on the hemodynamics of the circulatory system, investigations can be carried out using a model of the cardiovascular system. In this study, a previously developed hybrid (hydro-numerical) simulator of the cardiovascular system (HCS) was adapted and used. In our HCS Björk-Shiley mechanical heart valves were used, playing the role of mitral and aortic ones. In order to simulate aortic stenosis (AS) and mitral regurgitation (MR), special mechanical devices have been developed and integrated with the HCS. The simulation results proved that the system works correctly. Namely, in the case of AS - the mean pulmonary arterial pressure was increased due to increased preload of the left ventricle and the decrease in right ventricular preload was caused by a decrease in systemic arterial pressure. The severity of AS was performed based on the transaortic pressure gradient as well as using the Gorlin and Aaslid equations. In the case of severe AS, when the mean gradient was above 40 mmHg, the aortic valve orifice area was 0.5 cm2, which is in line with ACC/AHA guidelines. For the case of MR - with increasing severity of MR, there was a decrease in the left ventricular pressure and an increase in left atrial pressure. Using mechanical heart valves to simulate VHD by the HCS can be a valuable tool for biomedical research, providing a safe and controlled environment to study and understand the pathophysiology of VHD.
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Affiliation(s)
- Raman Pasledni
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Ks. Trojdena 4, 02-109 Warsaw, Poland.
| | - Maciej Kozarski
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Ks. Trojdena 4, 02-109 Warsaw, Poland
| | - Jeremi Kaj Mizerski
- Department of Cardiac Surgery, The Pope John Paul II Province Hospital, Aleje Jana Pawla II 10, 22-400 Zamosc, Poland
| | - Marek Darowski
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Ks. Trojdena 4, 02-109 Warsaw, Poland
| | - Piotr Okrzeja
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Ks. Trojdena 4, 02-109 Warsaw, Poland
| | - Krzysztof Zieliński
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Ks. Trojdena 4, 02-109 Warsaw, Poland
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Anand V, Scott CG, Lee AT, Rigolin VH, Kane GC, Michelena HI, Pislaru SV, Bagameri G, Pellikka PA. Prevalence and Prognostic Implications of Pulmonary Hypertension in Patients With Severe Aortic Regurgitation. JACC. ADVANCES 2024; 3:100827. [PMID: 38938846 PMCID: PMC11198242 DOI: 10.1016/j.jacadv.2024.100827] [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: 03/10/2023] [Revised: 11/02/2023] [Accepted: 12/03/2023] [Indexed: 06/29/2024]
Abstract
Background Pulmonary hypertension (PH) has been shown to be associated with worse outcomes in patients with aortic regurgitation (AR) in small older studies. Objectives The authors sought to evaluate the prevalence of PH in patients with severe AR, its impact on mortality and symptoms, and regression after aortic valve replacement (AVR). Methods A total of 821 consecutive patients with chronic ≥ moderate-severe AR on echocardiography from 2004 to 2019 were retrospectively analyzed. PH was defined as right ventricular systolic pressure (RVSP) >40 mm Hg on transthoracic echocardiogram (mild-moderate PH: RVSP 40-59 mm Hg, severe PH: RVSP > 60 mm Hg). Clinical and echocardiographic data were extracted from the electronic medical record and echocardiographic reports. The diastolic function and filling pressures were manually assessed and checked, and the left ventricular (LV) volumes were traced by a level 3-trained echocardiographer. The primary objectives were prevalence of PH in patients with ≥ moderate-severe AR, its risk associations and impact on all-cause mortality as the primary outcome. Secondary outcomes were impact of PH on symptoms and change in RVSP at discharge post-AVR. Logistic and Cox proportional hazards regression were used to analyze these outcomes. Results The mean age was 61.2 ± 17 years, and 162 (20%) were women. Mild-moderate PH was present in 91 (11%) patients and severe PH in 27 (3%). Larger LV size, elevated LV filling pressures, and ≥ moderate tricuspid regurgitation were associated with PH. During follow-up of 7.3 (6.3-7.9) years, 188 patients died. Compared to those without PH, risk of mortality was higher in mild-moderate PH (adjusted HR: 1.59 (95% CI: 1.07-2.36) (P = 0.021)) and severe PH (adjusted HR: 2.90 (95% CI: 1.63-5.15) (P < 0.001)). Symptoms were also more prevalent in those with PH (P = 0.004). Of 396 patients who underwent AVR during the study period, 57 had PH. AVR similarly improved survival in patients without and with PH (P for interaction = 0.23), and there was regression in RVSP (≥8 mm Hg drop) at discharge post-AVR in 35/57 (61%) patients with PH. Conclusions PH was present in 14% of patients with AR and was associated with higher mortality and symptoms. The survival benefit of AVR was similar in patients without and with PH.
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Affiliation(s)
- Vidhu Anand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher G. Scott
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander T. Lee
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Vera H. Rigolin
- Department of Cardiovascular Medicine, Northwestern University, Chicago, Illinois, USA
| | - Garvan C. Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hector I. Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sorin V. Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Gabor Bagameri
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Lindenfeld J, Costanzo MR, Zile MR, Ducharme A, Troughton R, Maisel A, Mehra MR, Paul S, Sears SF, Smart F, Johnson N, Henderson J, Adamson PB, Desai AS, Abraham WT. Implantable Hemodynamic Monitors Improve Survival in Patients With Heart Failure and Reduced Ejection Fraction. J Am Coll Cardiol 2024; 83:682-694. [PMID: 38325994 DOI: 10.1016/j.jacc.2023.11.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Trials evaluating implantable hemodynamic monitors to manage patients with heart failure (HF) have shown reductions in HF hospitalizations but not mortality. Prior meta-analyses assessing mortality have been limited in construct because of an absence of patient-level data, short-term follow-up duration, and evaluation across the combined spectrum of ejection fractions. OBJECTIVES The purpose of this meta-analysis was to determine whether management with implantable hemodynamic monitors reduces mortality in patients with heart failure and reduced ejection fraction (HFrEF) and to confirm the effect of hemodynamic-monitoring guided management on HF hospitalization reduction reported in previous studies. METHODS The patient-level pooled meta-analysis used 3 randomized studies (GUIDE-HF [Hemodynamic-Guided Management of Heart Failure], CHAMPION [CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients], and LAPTOP-HF [Left Atrial Pressure Monitoring to Optimize Heart Failure Therapy]) of implantable hemodynamic monitors (2 measuring pulmonary artery pressures and 1 measuring left atrial pressure) to assess the effect on all-cause mortality and HF hospitalizations. RESULTS A total of 1,350 patients with HFrEF were included. Hemodynamic-monitoring guided management significantly reduced overall mortality with an HR of 0.75 (95% CI: 0.57-0.99); P = 0.043. HF hospitalizations were significantly reduced with an HR of 0.64 (95% CI: 0.55-0.76); P < 0.0001. CONCLUSIONS Management of patients with HFrEF using an implantable hemodynamic monitor significantly reduces both mortality and HF hospitalizations. The reduction in HF hospitalizations is seen early in the first year of monitoring and mortality benefits occur after the first year.
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Affiliation(s)
- JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | | | - Michael R Zile
- Medical University of South Carolina, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Caroline, USA
| | - Anique Ducharme
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Richard Troughton
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Alan Maisel
- University of California San Diego, La Jolla, California, USA
| | - Mandeep R Mehra
- Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sara Paul
- Catawba Valley Health System, Conover, North Carolina, USA
| | - Samuel F Sears
- East Carolina University, Greenville, North Carolina, USA
| | - Frank Smart
- Louisiana State University School of Medicine, New Orleans, Louisiana, USA
| | | | | | | | - Akshay S Desai
- Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, Massachusetts, USA
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van de Veerdonk MC, Roosma L, Trip P, Gopalan D, Vonk Noordegraaf A, Dorfmüller P, Nossent EJ. Clinical-imaging-pathological correlation in pulmonary hypertension associated with left heart disease. Eur Respir Rev 2024; 33:230144. [PMID: 38417969 PMCID: PMC10900069 DOI: 10.1183/16000617.0144-2023] [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: 07/14/2023] [Accepted: 11/25/2023] [Indexed: 03/01/2024] Open
Abstract
Pulmonary hypertension (PH) is highly prevalent in patients with left heart disease (LHD) and negatively impacts prognosis. The most common causes of PH associated with LHD (PH-LHD) are left heart failure and valvular heart disease. In LHD, passive backward transmission of increased left-sided filling pressures leads to isolated post-capillary PH. Additional pulmonary vasoconstriction and remodelling lead to a higher vascular load and combined pre- and post-capillary PH. The increased afterload leads to right ventricular dysfunction and failure. Multimodality imaging of the heart plays a central role in the diagnostic work-up and follow-up of patients with PH-LHD. Echocardiography provides information about the estimated pulmonary artery pressure, morphology and function of the left and right side of the heart, and valvular abnormalities. Cardiac magnetic resonance imaging is the gold standard for volumetric measurements and provides myocardial tissue characterisation. Computed tomography of the thorax may show general features of PH and/or LHD and is helpful in excluding other PH causes. Histopathology reveals a spectrum of pre- and post-capillary vasculopathy, including intimal fibrosis, media smooth muscle cell hyperplasia, adventitial fibrosis and capillary congestion. In this paper, we provide an overview of clinical, imaging and histopathological findings in PH-LHD based on three clinical cases.
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Affiliation(s)
- Marielle C van de Veerdonk
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Lize Roosma
- Department of Pulmonary Diseases, Amsterdam University Medical Centers, Free University, Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Pia Trip
- Department of Pulmonary Diseases, Amsterdam University Medical Centers, Free University, Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Deepa Gopalan
- Department of Radiology, Imperial College Hospital NHS Trust, London, UK
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Diseases, Amsterdam University Medical Centers, Free University, Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Peter Dorfmüller
- Department of Pathology, University Hospital Giessen and Marburg (UKGM), German Centre for Lung Research (DZL) and Institute for Lung Health (ILH), Giessen, Germany
| | - Esther J Nossent
- Department of Pulmonary Diseases, Amsterdam University Medical Centers, Free University, Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
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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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Patel B, D'Souza S, Sahni T, Yehya A. Pulmonary hypertension secondary to valvular heart disease: a state-of-the-art review. Heart Fail Rev 2024; 29:277-286. [PMID: 38017225 DOI: 10.1007/s10741-023-10372-9] [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] [Accepted: 11/15/2023] [Indexed: 11/30/2023]
Abstract
Pulmonary hypertension (PH) is a common disease affecting up to 1% of the population and at least 50% of patients diagnosed with heart failure (HF) (Hoeper et al. in Lancet Respir Med 4(4):306-322, 2016). It is estimated that PH is present in 15% to 60% of patients with valvular heart disease (VHD) which can result from an increase in pulmonary blood flow and subsequently in pulmonary venous congestion and pulmonary vascular resistance (PVR). It is important to identify the severity of PH in patients with VHD to appropriately risk stratify and manage these patients (Magne et al. in JACC Cardiovasc Imaging 8(1):83-99, 2015). In this review, we examine the diagnostic criteria for PH and its pathophysiology. We also focus on the growing evidence supporting the presence of PH secondary to VHD and describe the contemporary surgical and medical therapeutic interventions in this patient population (Fig. 1).
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Affiliation(s)
- Bansi Patel
- Virginia Hospital Center, Arlington, VA, USA
| | | | - Tamanna Sahni
- Kaiser Permanente Internal Medicine Residency, Gaithersburg, MD, USA
| | - Amin Yehya
- Sentara Advanced Heart Failure Center, Norfolk, VA, USA.
- Eastern Virginia Medical School, Norfolk, VA, USA.
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Cardaioli F, Nai Fovino L, Fabris T, Masiero G, Arturi F, Trevisanello A, Zuccarelli V, Napodano M, Fraccaro C, Continisio S, Tarantini G. Updated definition of pulmonary hypertension and outcome after transcatheter aortic valve implantation. Heart 2023; 110:27-34. [PMID: 37414524 DOI: 10.1136/heartjnl-2023-322881] [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: 04/26/2023] [Accepted: 06/22/2023] [Indexed: 07/08/2023] Open
Abstract
OBJECTIVE The European Society of Cardiology guidelines have recently defined new cut-offs for pulmonary hypertension (PH) and pulmonary vasculature resistance (PVR; median pulmonary artery pressure (mPAP) >20 instead of 25 mm Hg and PVR >2 instead of 3 Wood unit). The prognostic value of this updated classification after transcatheter aortic valve implantation (TAVI) is unknown. METHODS 579 consecutive patients treated by TAVI with preprocedural right heart catheterisation evaluation were included. Patients were grouped as: (1) no PH, (2) isolated precapillary/combined (I-PreC/Co) PH and (3) isolated postcapillary PH (I-PoC). All-cause death, cardiovascular death and hospitalisations for heart failure (HF) were evaluated at follow-up. We also analysed the prognostic role of residual postprocedural PH. RESULTS Out of 579 patients, 299 (52%) had PH according to the new criteria compared with 185 (32%) according to the previous ones. Overall median age was 82 years, while 55.3% patients were male. Patients with PH were more frequently diagnosed with chronic obstructive pulmonary disease and atrial fibrillation and were characterised by higher surgical risk as compared with patients without PH.At a median follow-up of 2.9 years, the presence of PH according to previous definition was associated with worse survival (p<0.001) and HF hospitalisation (p=0.002) rates, irrespective of PVR values. With newer cut-offs, PH was associated with worse outcomes only in patients with increased PVR, while no differences were found between patients with PH and normal PVR values and those without PH. Postprocedural mPAP normalisation was observed in 45% of the cases, but it was associated with improved long-term survival only in the I-PoC PH group. CONCLUSIONS New ESC PH cut-offs increased the number of PH diagnoses. The presence of PH, particularly in the setting of increased PVR, identify patients at higher risk for postprocedural mortality and rehospitalisation. Normalisation of PH was associated with better survival only in I-PoC group.
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Affiliation(s)
- Francesco Cardaioli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Luca Nai Fovino
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Tommaso Fabris
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Giulia Masiero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Federico Arturi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Aurora Trevisanello
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Vittorio Zuccarelli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Massimo Napodano
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Saverio Continisio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
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Güder G, Reiter T, Fette G, Hundertmark M, Frantz S, Morbach C, Störk S, Held M. Diagnosing post-capillary hypertension in patients with left heart disease: impact of new guidelines. Clin Res Cardiol 2023:10.1007/s00392-023-02290-5. [PMID: 37668664 DOI: 10.1007/s00392-023-02290-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 08/17/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND In 2022, the definition of pulmonary hypertension (PH) in the presence of left heart disease was updated according to the new joint guidelines of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS). The impact of the new ESC/ERS definition on the prevalence of post-capillary PH (pc-PH) and its subgroups of isolated post-capillary (Ipc-PH) and combined pre- and post-capillary PH (Cpc-PH) in patients with left heart disease is unclear. METHODS We retrospectively identified N = 242 patients with left heart disease with available data on right heart catheterisation (RHC) and cardiac magnetic resonance imaging (CMR). The proportion of pc-PH and its subgroups was calculated according to the old and new ESC/ERS PH definition. As the old definition did not allow the exact allocation of all patients with pc-PH into a respective subgroup, unclassifiable patients (Upc-PH) were regarded separately. RESULTS Seventy-six out of 242 patients had pc-PH according to the new ESC/ERS definitions, with 72 of these patients also meeting the criteria of the old definition. Using the old definition, 50 patients were diagnosed with Ipc-PH, 4 with Cpc-PH, and 18 with Upc-PH. Applying the new definition, Ipc-PH was diagnosed in 35 patients (4 newly), and Cpc-PH in 41 patients. No CMR parameter allowed differentiating between Ipc-PH and Cpc-PH, regardless of which guideline version was used. CONCLUSION Applying the new ESC/ERS 2022 guideline definitions mildly increased the proportion of patients diagnosed with pc-PH (+ 5.5%) but markedly increased Cpc-PH diagnoses. This effect was driven by the allocation of patients with formerly unclassifiable forms of post-capillary PH to the Cpc-PH subgroup and a significant shift of patients from the Ipc-PH to the Cpc-PH subgroup. Distribution of post-capillary pulmonary hypertension (pc-PH) subgroups according to the European Society of Cardiology/European Respiratory Society (ESC/ERS) PH guidelines from 2015 and 2022 in N = 242 patients with left heart disease.
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Affiliation(s)
- Gülmisal Güder
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany.
- Department of Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany.
| | - Theresa Reiter
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Georg Fette
- Department of Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
- Chair of Computer Science VI, University of Würzburg, Würzburg, Germany
| | - Moritz Hundertmark
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Stefan Frantz
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
- Department of Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - Caroline Morbach
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
- Department of Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Störk
- Department of Internal Medicine I, Cardiology Division, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
- Department of Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - Matthias Held
- Department of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital, Central Clinic Würzburg, Würzburg, Germany
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Velidakis N, Khattab E, Gkougkoudi E, Kadoglou NPE. Pulmonary Hypertension in Left Ventricular Valvular Diseases: A Comprehensive Review on Pathophysiology and Prognostic Value. Life (Basel) 2023; 13:1793. [PMID: 37763197 PMCID: PMC10532440 DOI: 10.3390/life13091793] [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: 07/05/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 09/29/2023] Open
Abstract
Left ventricular (LV) valvular diseases, make up one of the most common etiologies for pulmonary hypertension (PH), and it is not well understood how and at which degree it affects prognosis. The aim of the present study was a comprehensive review of the pathophysiologic mechanism of PH in patients with LV valvular diseases and the prognostic value of baseline and post-intervention PH in patients undergoing interventional treatment. The pathophysiology of PH in patients with LV valvular diseases involves gradual elevation of left ventricular filling pressure and left atrial pressure, which are passively transmitted to the pulmonary circulation and raise pulmonary artery systolic pressure (PASP). A long-lasting exposure to elevated PASP progressively leads to initially functional and thereafter irreversible structural changes in the pulmonary vasculature, leading up to high pulmonary vascular resistance. Surgical treatment of severe LV valvular diseases is highly effective in patients without resting PH or those with exercise-induced PH (EIPH) before intervention. In the case of pre-operative PH, successful interventional therapy decreases PASP, but the post-operative cardiac and all-cause mortality remain higher compared to patients without pre-operative PH. Hence, it is of paramount importance to detect patients with severe LV valvulopathies before the development of PH, since they will get greater benefits from early intervention.
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Affiliation(s)
| | | | | | - Nikolaos P. E. Kadoglou
- Medical School, University of Cyprus, Palaios Dromos Lefkosias Lemesou No. 215/62029 Aglantzia, P.O. Box 20537 1678, Nicosia 2024, Cyprus
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Ratwatte S, Playford D, Stewart S, Strange G, Celermajer DS. Prevalence of pulmonary hypertension in aortic regurgitation and its influence on outcomes. Heart 2023; 109:1310-1318. [PMID: 37012044 DOI: 10.1136/heartjnl-2022-322187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/02/2023] [Indexed: 04/05/2023] Open
Abstract
OBJECTIVE Aortic regurgitation (AR) can lead to pulmonary hypertension (PHT). There is a paucity of data on the prognostic importance of PHT in these patients. We therefore aimed to describe the prevalence and prognostic importance of PHT in such patients. METHODS In this retrospective study, we analysed the National Echocardiography Database of Australia (data from 2000 to 2019). Adults with an estimated right ventricular systolic pressure (eRVSP), left ventricular ejection fraction (LVEF) >50% and with moderate or greater AR were included (n=8392). These subjects were then categorised according to their eRVSP. The relationship between PHT severity and mortality outcomes were evaluated (median follow-up of 3.1 years, IQR 1.5-5.7 years). RESULTS Subjects were aged 74±14 years and 58.4% (4901) were female. Overall, 1417 (16.9%) had no PHT, and 3253 (38.8%), 2249 (26.9%), 893 (10.6%) and 580 (6.9%) patients had borderline, mild, moderate and severe PHT, respectively. Mean eRVSP was slightly higher in females than males (41±13 vs 39±12 mm Hg, p<0.0001) and increased with age in both sexes. After adjustment for age and sex, the risk of long-term mortality increased as eRVSP increased (adjusted HR (aHR) 1.20, 95% CI 1.06 to 1.36 in borderline PHT, to aHR 3.32, 95% CI 2.85 to 3.86 in severe PHT, p<0.0001). There was a mortality threshold seen from mild PHT onwards (eRVSP 41.36-44.15 mm Hg; aHR 1.41, 95%CI 1.17 to 1.68). CONCLUSIONS In this large cohort study, we characterise the relationship between AR and PHT in adults. In patients with ≥moderate AR, PHT is associated with a progressive risk of mortality, even at mildly elevated levels.
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Affiliation(s)
- Seshika Ratwatte
- Department of Cardiology, Royal Prince Albert Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David Playford
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Simon Stewart
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Geoff Strange
- Heart Research Institute Ltd, Newtown, New South Wales, Australia
- The University of Notre Dame Australia School of Medicine, Fremantle, Western Australia, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Albert Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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12
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Ratwatte S, Stewart S, Strange G, Playford D, Celermajer DS. Prevalence of pulmonary hypertension in aortic stenosis and its influence on outcomes. Heart 2023; 109:1319-1326. [PMID: 37012043 DOI: 10.1136/heartjnl-2022-322184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/21/2023] [Indexed: 04/05/2023] Open
Abstract
OBJECTIVE The significance of pulmonary hypertension (PHT) complicating aortic stenosis (AS) is poorly characterised. In a large cohort of adults with at least moderate AS, we aimed to describe the prevalence and prognostic importance of PHT in such patients. METHODS In this retrospective study, we analysed the National Echocardiography Database of Australia (data from 2000 to 2019). Adults with an estimated right ventricular systolic pressure (eRVSP), left ventricular ejection fraction (LVEF) >50% and with moderate or greater AS were included (n=14 980). These subjects were then categorised according to their eRVSP. The relationship between PHT severity and mortality outcomes were evaluated (median follow-up of 2.6 years, IQR 1.0-4.6 years). RESULTS Subjects were aged 77±13 years and 57.4% were female. Overall, 2049 (13.7%), 5085 (33.9%), 4380 (29.3%), 1956 (13.1%) and 1510 (10.1%) patients had no (eRVSP<30.00 mm Hg), borderline (30.00-39.99 mm Hg), mild (40.00-49.99 mm Hg), moderate (50.00-59.99 mm Hg) and severe PHT (>60.00 mm Hg), respectively. An echocardiographic phenotype was evident with worsening PHT, showing rising E:e' ratio and right and left atrial sizes(p<0.0001, for all). Adjusted analyses showed that the risk of long-term mortality progressively rose as eRVSP level increased (HR 1.14-2.94, borderline to severe PHT, p<0.0001 for all). A mortality threshold was identified in the 4th decile of eRVSP categories (35.01-38.00 mm Hg; HR 1.19, 95% CI 1.04 to 1.35), with risk progressively increasing through to the 10th decile (HR 2.86, 95% CI 2.54 to 3.21). CONCLUSIONS In this large cohort study, we find that PHT is common in ≥moderate AS and mortality increases as PHT becomes more severe. A threshold for higher mortality lies within the range of 'borderline-mild' PHT. TRIAL REGISTRATION NUMBER ACTRN12617001387314.
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Affiliation(s)
- Seshika Ratwatte
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- School of Medicine and Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Simon Stewart
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Geoff Strange
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
- Heart Research Institute Ltd, Newtown, Sydney, Australia
| | - David Playford
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- School of Medicine and Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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13
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Viva T, Postolache A, Nguyen Trung ML, Danthine P, Petitjean H, Bruno VD, Martinez C, Lempereur M, Guazzi M, Aghezzaf S, Coisne A, Oury C, Dulgheru R, Lancellotti P. A new integrative approach combining right heart catheterization and echocardiography to stage aortic stenosis-related cardiac damage. Front Cardiovasc Med 2023; 10:1184308. [PMID: 37600042 PMCID: PMC10436206 DOI: 10.3389/fcvm.2023.1184308] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 07/13/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction Although staging of the extent of aortic stenosis (AS)-related cardiac damages is usually performed via echocardiography, this technique has considerable limitations in assessing pulmonary artery and right chamber pressures. The present hypothesis-generating study sought to explore the efficacy of a staging system of cardiac damage based on echocardiographic and invasive [right heart catheterization (RHC)] hemodynamic parameters in patients undergoing transcatheter aortic valve implantation (TAVI). Methods We studied 90 symptomatic patients with severe AS in whom echocardiographic and invasive evaluation by RHC was obtained prior to TAVI. Cardiac damage stages were defined as follows: no cardiac damage (stage 0), left ventricular (LV) damage (stage 1), left atrial or mitral valve damage (stage 2), pulmonary vasculature or tricuspid valve damage (stage 3), and right ventricular (RV) dysfunction or low-flow state (stage 4). With the integrative approach using RHC, pulmonary hypertension (PH) was defined as an mPAP ≥25 mmHg and the low-flow state corresponded to a cardiac index of <1.8 L/min/m2 and a right atrial pressure of >10 mmHg. Results During follow-up (median: 2.9 years), 43 patients (47.8%) died. The integrative cardiac damage staging was associated with a significant increase in all-cause and cardiovascular mortality per each increase of cardiac damage stage, whereas the outcome was similar according to the echocardiographic staging. Conclusions A staging system of cardiac lesion based on echocardiographic and invasive hemodynamic parameters in patients with severe AS undergoing TAVI predicts mortality. Patients with pre-existing PH, ≥ moderate tricuspid regurgitation and/or RV dysfunction, and a low-flow state had a markedly increased risk of death. Further larger studies are needed to validate our findings.
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Affiliation(s)
- Tommaso Viva
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
- Department of Biomedical Sciences for Health, University of Milano, Milan, Italy
- Department of Minimally Invasive Cardiac Surgery, IRCCS Galeazzi—Sant’Ambrogio Hospital, Milan, Italy
| | - Adriana Postolache
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
| | - Mai-Linh Nguyen Trung
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
| | - Pauline Danthine
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
| | - Hélène Petitjean
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
| | - Vito Domenico Bruno
- Department of Minimally Invasive Cardiac Surgery, IRCCS Galeazzi—Sant’Ambrogio Hospital, Milan, Italy
| | - Christophe Martinez
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
| | - Mathieu Lempereur
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
| | - Marco Guazzi
- School of Medicine, Department of Biological Sciences, University of Milano, Milan, Italy
- CardiologyDivision, San Paolo Hospital, Milan, Italy
| | - Samy Aghezzaf
- CHU Lille, Institut Pasteur de Lille, University Lille, Inserm, Lille, France
| | - Augustin Coisne
- CHU Lille, Institut Pasteur de Lille, University Lille, Inserm, Lille, France
- Cardiovascular Research Foundation, New York, NY, United States
| | - Cécile Oury
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
| | - Raluca Dulgheru
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
| | - Patrizio Lancellotti
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
- Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
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14
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Chioncel O, Adamo M, Nikolaou M, Parissis J, Mebazaa A, Yilmaz MB, Hassager C, Moura B, Bauersachs J, Harjola VP, Antohi EL, Ben-Gal T, Collins SP, Iliescu VA, Abdelhamid M, Čelutkienė J, Adamopoulos S, Lund LH, Cicoira M, Masip J, Skouri H, Gustafsson F, Rakisheva A, Ahrens I, Mortara A, Janowska EA, Almaghraby A, Damman K, Miro O, Huber K, Ristic A, Hill L, Mullens W, Chieffo A, Bartunek J, Paolisso P, Bayes-Genis A, Anker SD, Price S, Filippatos G, Ruschitzka F, Seferovic P, Vidal-Perez R, Vahanian A, Metra M, McDonagh TA, Barbato E, Coats AJS, Rosano GMC. Acute heart failure and valvular heart disease: A scientific statement of the Heart Failure Association, the Association for Acute CardioVascular Care and the European Association of Percutaneous Cardiovascular Interventions of the European Society of Cardiology. Eur J Heart Fail 2023; 25:1025-1048. [PMID: 37312239 DOI: 10.1002/ejhf.2918] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/09/2023] [Accepted: 05/18/2023] [Indexed: 06/15/2023] Open
Abstract
Acute heart failure (AHF) represents a broad spectrum of disease states, resulting from the interaction between an acute precipitant and a patient's underlying cardiac substrate and comorbidities. Valvular heart disease (VHD) is frequently associated with AHF. AHF may result from several precipitants that add an acute haemodynamic stress superimposed on a chronic valvular lesion or may occur as a consequence of a new significant valvular lesion. Regardless of the mechanism, clinical presentation may vary from acute decompensated heart failure to cardiogenic shock. Assessing the severity of VHD as well as the correlation between VHD severity and symptoms may be difficult in patients with AHF because of the rapid variation in loading conditions, concomitant destabilization of the associated comorbidities and the presence of combined valvular lesions. Evidence-based interventions targeting VHD in settings of AHF have yet to be identified, as patients with severe VHD are often excluded from randomized trials in AHF, so results from these trials do not generalize to those with VHD. Furthermore, there are not rigorously conducted randomized controlled trials in the setting of VHD and AHF, most of the data coming from observational studies. Thus, distinct to chronic settings, current guidelines are very elusive when patients with severe VHD present with AHF, and a clear-cut strategy could not be yet defined. Given the paucity of evidence in this subset of AHF patients, the aim of this scientific statement is to describe the epidemiology, pathophysiology, and overall treatment approach for patients with VHD who present with AHF.
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Affiliation(s)
- Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Maria Nikolaou
- Cardiology Department, General Hospital 'Sismanogleio-Amalia Fleming', Athens, Greece
| | - John Parissis
- Heart Failure Unit and University Clinic of Emergency Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Alexandre Mebazaa
- Université Paris Cité, MASCOT Inserm, Hôpitaux Universitaires Saint Louis Lariboisière, APHP, Paris, France
| | - Mehmet Birhan Yilmaz
- Division of Cardiology, Department of Internal Medical Sciences, School of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet and Dept of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Brenda Moura
- Armed Forces Hospital, Faculty of Medicine of Porto, Porto, Portugal
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Elena-Laura Antohi
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | - Tuvia Ben-Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA
| | - Vlad Anton Iliescu
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | - Magdy Abdelhamid
- Faculty of Medicine, Kasr Al Ainy, Cardiology Department, Cairo University, Cairo, Egypt
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius; Centre of Innovative Medicine, Vilnius, Lithuania
| | | | - Lars H Lund
- Karolinska Institute, Department of Medicine, and Karolinska University Hospital, Department of Cardiology, Stockholm, Sweden
| | | | - Josep Masip
- Research Direction, Consorci Sanitari Integral, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - Hadi Skouri
- Division of Cardiology, Internal Medicine Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Amina Rakisheva
- Scientific and Research Institute of Cardiology and Internal Disease, Almaty, Kazakhstan
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital, Cologne, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andrea Mortara
- Department of Cardiology, Policlinico di Monza, Monza, Italy
| | - Ewa A Janowska
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Abdallah Almaghraby
- Cardiology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Oscar Miro
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Kurt Huber
- Medical Faculty, Sigmund Freud University, Vienna, Austria
- 3rd Medical Department, Wilhelminen Hospital, Vienna, Austria
| | - Arsen Ristic
- Department of Cardiology of the University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Loreena Hill
- School of Nursing & Midwifery, Queen's University, Belfast, UK
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- UHasselt, Biomedical Research Institute, Faculty of Medicine and Life Sciences, LCRC, Diepenbeek, Belgium
| | - Alaide Chieffo
- Vita Salute-San Raffaele University, Milan, Italy
- IRCCS San Raffaele Scientific, Institute, Milan, Italy
| | - Jozef Bartunek
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
| | - Pasquale Paolisso
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Antoni Bayes-Genis
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité, Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Susanna Price
- Royal Brompton Hospital & Harefield NHS Foundation Trust, London, UK
| | - Gerasimos Filippatos
- Heart Failure Unit, Department of Cardiology, Athens University Hospital, Attikon, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Department of Cardiology, Center for Translational and Experimental Cardiology (CTEC), University Hospital Zurich, Zurich, Switzerland
| | - Petar Seferovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Rafael Vidal-Perez
- Department of Cardiology, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Alec Vahanian
- University Paris Cite, INSERM LVTS U 1148 Bichat, Paris, France
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Theresa A McDonagh
- Department of Cardiology, King's College Hospital London, London, UK
- School of Cardiovascular Medicine and Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
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Barbieri A, Mantovani F. Exercise Stress Echocardiography in Asymptomatic Patients With Severe Primary Mitral Regurgitation: Time to Stepping Out Our Comfort Zone. Am J Cardiol 2023:S0002-9149(23)00435-6. [PMID: 37394404 DOI: 10.1016/j.amjcard.2023.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/05/2023] [Accepted: 06/11/2023] [Indexed: 07/04/2023]
Affiliation(s)
- Andrea Barbieri
- Division of Cardiology, Department of Diagnostics, Clinical and Public Health Medicine, Policlinico University Hospital of Modena, Modena, Italy.
| | - Francesca Mantovani
- Cardiology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Italy
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16
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Kew EP, Caruso V, Grapsa J, Bosco P, Lucchese G. Predictors of Outcome in Patients with Pulmonary Hypertension Undergoing Mitral and Tricuspid Valve Surgery. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1103. [PMID: 37374307 PMCID: PMC10302326 DOI: 10.3390/medicina59061103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 06/02/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: Pulmonary hypertension (PH) secondary to left-sided valvular heart disease is associated with poor cardiac surgical outcome compared with patients without PH. Our objective was to investigate the prognostic factors of surgical outcome in patients with PH undergoing mitral valve (MV) and tricuspid valve (TV) surgery, in order to risk stratify their management. Materials and Methods: This is a retrospective observational study on patients with PH who underwent MV and TV surgery from 2011 to 2019. The primary outcome was all-cause mortality. The secondary outcomes were post-op respiratory and renal complications, length of intensive care unit stay and length of hospital stay. Results: Seventy-six patients were included in this study. The all-cause mortality was 13% (n = 10), with mean survival of 92.6 months. Among the patients, 9.2% (n = 7) had post-op renal failure requiring renal replacement therapy and 6.6% (n = 5) had post-op respiratory failure requiring intubation. Univariate analysis demonstrated that pre-operative left ventricular ejection fraction (LVEF), peak systolic tissue velocity at the tricuspid annulus (S') and etiology of MV disease were associated with respiratory and renal failure. Tricuspid annular plane systolic excursion (TAPSE) was associated with respiratory failure only. S', type of operation, LVEF, urgency of surgery, and etiology of MV disease were found to be predictive of mortality. After excluding redo mitral surgery, all statistically significant findings remain unchanged, with the addition of right ventricular (RV) size being associated with respiratory failure. In the subgroup analysis of routine cases (n = 56), patients with primary mitral regurgitation who underwent mitral valve repair had better survival outcome. Conclusions: Urgency of surgery, etiology of MV disease, type of operation (replacement or repair), S' and pre-op LVEF are prognostic indicators in this small cohort of patients with PH undergoing MV and TV surgery. A larger prospective study is warranted to validate our findings.
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Affiliation(s)
- Ee Phui Kew
- Department of Cardiac Surgery, St. Thomas Hospital London, London SE1 7EH, UK (G.L.)
| | - Vincenzo Caruso
- Department of Cardiac Surgery, St. Thomas Hospital London, London SE1 7EH, UK (G.L.)
| | - Julia Grapsa
- Department of Cardiology, St. Thomas Hospital London, London SE1 7EH, UK
| | - Paolo Bosco
- Department of Cardiac Surgery, St. Thomas Hospital London, London SE1 7EH, UK (G.L.)
| | - Gianluca Lucchese
- Department of Cardiac Surgery, St. Thomas Hospital London, London SE1 7EH, UK (G.L.)
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17
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Left atrial size predicts outcome in severe but asymptomatic mitral regurgitation. Sci Rep 2023; 13:3892. [PMID: 36890195 PMCID: PMC9995476 DOI: 10.1038/s41598-023-31163-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/07/2023] [Indexed: 03/10/2023] Open
Abstract
Patients with severe asymptomatic primary mitral regurgitation (MR) can be safely managed with an active surveillance strategy. Left atrial (LA) size is affected by MR severity, left ventricular function and is also associated with the risk of atrial fibrillation and may be an integrative parameter for risk stratification. The present study sought to determine the predictive value of LA size in a large series of asymptomatic patients with severe MR. 280 consecutive patients (88 female, median age 58 years) with severe primary MR and no guideline-based indications for surgery were included in a follow-up program until criteria for mitral surgery were reached. Event-free survival was determined and potential predictors of outcome were assessed. Survival free of any indication for surgery was 78% at 2 years, 52% at 6 years, 35% at 10 years and 19% at 15 years, respectively. Left atrial (LA) diameter was the strongest independent echocardiographic predictor of event-free survival with incremental predictive value for the thresholds of 50, 60 and 70 mm, respectively. In a multivariable analysis that encompassed age at baseline, previous history of atrial fibrillation, left ventricular end systolic diameter), LA diameter, sPAP > 50 mmHg and year of inclusion, LA diameter was the strongest independent echocardiographic predictor of event-free survival (adjusted HR = 1.039, p < 0.001). LA size is a simple and reproducible predictor of outcome in asymptomatic severe primary MR. In particular, it may help to identify patients who may benefit from early elective valve surgery in heart valve centers of excellence.
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18
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Butcher SC, Essayagh B, Steyerberg EW, Benfari G, Antoine C, Grigioni F, Le Tourneau T, Roussel JC, van Wijngaarden A, Marsan NA, Tribouilloy C, Rusinaru D, Hochstadt A, Topilsky Y, Michelena HI, Delgado V, Bax JJ, Enriquez-Sarano M. Factors influencing post-surgical survival in degenerative mitral regurgitation. Eur Heart J 2023; 44:871-881. [PMID: 36702625 DOI: 10.1093/eurheartj/ehad004] [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: 07/17/2022] [Revised: 11/23/2022] [Accepted: 01/04/2023] [Indexed: 01/28/2023] Open
Abstract
AIMS Indications for surgery in patients with degenerative mitral regurgitation (DMR) are increasingly liberal in all clinical guidelines but the role of secondary outcome determinants (left atrial volume index ≥60 mL/m2, atrial fibrillation, pulmonary artery systolic pressure ≥50 mmHg and moderate to severe tricuspid regurgitation) and their impact on post-operative outcome remain disputed. Whether these secondary outcome markers are just reflective of the DMR severity or intrinsically affect survival after DMR surgery is uncertain and may have critical importance in the management of patients with DMR. To address these gaps of knowledge the present study gathered a large cohort of patients with quantified DMR, accounted for the number of secondary outcome markers and examined their independent impact on survival after surgical correction of the DMR. METHODS AND RESULTS The Mitral Regurgitation International DAtabase-Quantitative registry includes patients with isolated DMR from centres across North America, Europe, and the Middle East. Patient enrolment extended from January 2003 to January 2020. All patients undergoing mitral valve surgery within 1 year of registry enrolment were selected. A total of 2276 patients [65 (55-73) years, 32% male] across five centres met study eligibility criteria. Over a median follow-up of 5.6 (3.6 to 8.7) years, 278 patients (12.2%) died. In a comprehensive multivariable Cox regression model adjusted for age, EuroSCORE II, symptoms, left ventricular ejection fraction (LVEF), left ventricular end-systolic diameter (LV ESD) and DMR severity, the number of secondary outcome determinants was independently associated with post-operative all-cause mortality, with adjusted hazard ratios of 1.56 [95% confidence interval (CI): 1.11-2.20, P = 0.011], 1.78 (95% CI: 1.23-2.58, P = 0.002) and 2.58 (95% CI: 1.73-3.83, P < 0.0001) for patients with one, two, and three or four secondary outcome determinants, respectively. A model incorporating the number of secondary outcome determinants demonstrated a higher C-index and was significantly more concordant with post-operative mortality than models incorporating traditional Class I indications alone [the presence of symptoms (P = 0.0003), or LVEF ≤60% (P = 0.006), or LV ESD ≥40 mm (P = 0.014)], while there was no significant difference in concordance observed compared with a model that incorporated the number of Class I indications for surgery combined (P = 0.71). CONCLUSION In this large cohort of patients treated surgically for DMR, the presence and number of secondary outcome determinants was independently associated with post-surgical survival and demonstrated better outcome discrimination than traditional Class I indications for surgery. Randomised controlled trials are needed to determine if patients with severe DMR who demonstrate a cardiac phenotype with an increasing number of secondary outcome determinants would benefit from earlier surgery.
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Affiliation(s)
- Steele C Butcher
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands.,Department of Cardiology, Royal Perth Hospital, Victoria Square, Perth WA 6000, Australia
| | - Benjamin Essayagh
- Mayo Clinic Cardiovascular Medicine, 200 First St. SW Rochester, MN 55905, USA.,Department of Cardiovascular Medicine, Simone Veil Hospital, 15 Avenue des Broussailles, Cannes 06400, France
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Giovanni Benfari
- Mayo Clinic Cardiovascular Medicine, 200 First St. SW Rochester, MN 55905, USA
| | - Clemence Antoine
- Mayo Clinic Cardiovascular Medicine, 200 First St. SW Rochester, MN 55905, USA
| | - Francesco Grigioni
- University Campus Bio-Medico, Department of Cardiology, Via Álvaro del Portillo, 200, 00128 Roma RM, Italy
| | - Thierry Le Tourneau
- University of Nantes, Department of Cardiology, CHU de Nantes, 44093 Nantes, France
| | | | - Aniek van Wijngaarden
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Christophe Tribouilloy
- University of Amiens, Department of Cardiology, Centre Hospitalier Universitaire d'Amiens-Picardie, 80000 Amiens, France
| | - Dan Rusinaru
- University of Amiens, Department of Cardiology, Centre Hospitalier Universitaire d'Amiens-Picardie, 80000 Amiens, France
| | - Aviram Hochstadt
- The Tel-Aviv Medical Center and Sackler Faculty of Medicine, Department of Cardiology, 6 Weizmann Street, Tel Aviv 6423906, Israel
| | - Yan Topilsky
- The Tel-Aviv Medical Center and Sackler Faculty of Medicine, Department of Cardiology, 6 Weizmann Street, Tel Aviv 6423906, Israel
| | - Hector I Michelena
- Mayo Clinic Cardiovascular Medicine, 200 First St. SW Rochester, MN 55905, USA
| | - Victoria Delgado
- Department of Cardiology, Universtiy Hospital Germans Trias i Pujol, Carretera de Canyet, 08916 Badalona, Spain
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands.,Turku Heart Center, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, 20521 Turku, Finland
| | - Maurice Enriquez-Sarano
- Mayo Clinic Cardiovascular Medicine, 200 First St. SW Rochester, MN 55905, USA.,Department of Cardiovascular Diseases, Minneapolis Heart Institute, Abbott Northwestern Hospital, 800 E 28th St, Minneapolis, MN 55407, USA
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19
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Gerges C, Pistritto AM, Gerges M, Friewald R, Hartig V, Hofbauer TM, Reil B, Engel L, Dannenberg V, Kastl SP, Skoro-Sajer N, Moser B, Taghavi S, Klepetko W, Lang IM. Left Ventricular Filling Pressure in Chronic Thromboembolic Pulmonary Hypertension. J Am Coll Cardiol 2023; 81:653-664. [PMID: 36792280 DOI: 10.1016/j.jacc.2022.11.049] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by obstruction of major pulmonary arteries with organized thrombi. Clinical risk factors for pulmonary hypertension due to left heart disease including metabolic syndrome, left-sided valvular heart disease, and ischemic heart disease are common in CTEPH patients. OBJECTIVES The authors sought to investigate prevalence and prognostic implications of elevated left ventricular filling pressures (LVFP) in CTEPH. METHODS A total of 593 consecutive CTEPH patients undergoing a first diagnostic right and left heart catheterization were included in this study. Mean pulmonary arterial wedge pressure (mPAWP) and left ventricular end-diastolic pressure (LVEDP) were utilized for assessment of LVFP. Two cutoffs were applied to identify patients with elevated LVFP: 1) for the primary analysis mPAWP and/or LVEDP >15 mm Hg, as recommended by the current pulmonary hypertension guidelines; and 2) for the secondary analysis mPAWP and/or LVEDP >11 mm Hg, representing the upper limit of normal. Clinical and echocardiographic features, and long-term mortality were assessed. RESULTS LVFP was >15 mm Hg in 63 (10.6%) and >11 mm Hg in 222 patients (37.4%). Univariable logistic regression analysis identified age, systemic hypertension, diabetes, atrial fibrillation, calcific aortic valve stenosis, mitral regurgitation, and left atrial volume as significant predictors of elevated LVFP. Atrial fibrillation, calcific aortic valve stenosis, mitral regurgitation, and left atrial volume remained independent determinants of LVFP in adjusted analysis. At follow-up, higher LVFPs were measured in patients who had meanwhile undergone pulmonary endarterectomy (P = 0.002). LVFP >15 mm Hg (P = 0.021) and >11 mm Hg (P = 0.006) were both associated with worse long-term survival. CONCLUSIONS Elevated LVFP is common, appears to be due to comorbid left heart disease, and predicts prognosis in CTEPH.
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Affiliation(s)
- Christian Gerges
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | - Mario Gerges
- Department of Internal Medicine V, Division of Cardiology, Clinic Favoriten, Vienna, Austria
| | - Richard Friewald
- Department of Internal Medicine I, Division of Cardiology, University Hospital of Krems, Krems an der Donau, Austria; Karl Landsteiner Private University for Health Sciences, Krems an der Donau, Austria
| | - Valerie Hartig
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Thomas M Hofbauer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Benedikt Reil
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Leon Engel
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Varius Dannenberg
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Stefan P Kastl
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Nika Skoro-Sajer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Bernhard Moser
- Department of Surgery, Division of Thoracic Surgery, Medical University Vienna, Vienna, Austria
| | - Shahrokh Taghavi
- Department of Surgery, Division of Thoracic Surgery, Medical University Vienna, Vienna, Austria
| | - Walter Klepetko
- Department of Surgery, Division of Thoracic Surgery, Medical University Vienna, Vienna, Austria
| | - Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria.
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20
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Elmi-Sarabi M, Jarry S, Couture EJ, Haddad F, Cogan J, Sweatt AJ, Rousseau-Saine N, Beaubien-Souligny W, Fortier A, Denault AY. Pulmonary Vasodilator Response of Combined Inhaled Epoprostenol and Inhaled Milrinone in Cardiac Surgical Patients. Anesth Analg 2023; 136:282-294. [PMID: 36121254 DOI: 10.1213/ane.0000000000006192] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pulmonary hypertension (PH) and right ventricular (RV) dysfunction are major complications in cardiac surgery. Intraoperative management of patients at high risk of RV failure should aim to reduce RV afterload and optimize RV filling pressures, while avoiding systemic hypotension, to facilitate weaning from cardiopulmonary bypass (CPB). Inhaled epoprostenol and inhaled milrinone (iE&iM) administered in combination before CPB may represent an effective strategy to facilitate separation from CPB and reduce requirements for intravenous inotropes during cardiac surgery. Our primary objective was to report the rate of positive pulmonary vasodilator response to iE&iM and, second, how it relates to perioperative outcomes in cardiac surgery. METHODS This is a retrospective cohort study of consecutive patients with PH or RV dysfunction undergoing on-pump cardiac surgery at the Montreal Heart Institute from July 2013 to December 2018 (n = 128). iE&iM treatment was administered using an ultrasonic mesh nebulizer before the initiation of CPB. Demographic and baseline clinical data, as well as hemodynamic, intraoperative, and echocardiographic data, were collected using electronic records. An increase of 20% in the mean arterial pressure (MAP) to mean pulmonary artery pressure (MPAP) ratio was used to indicate a positive response to iE&iM. RESULTS In this cohort, 77.3% of patients were responders to iE&iM treatment. Baseline systolic pulmonary artery pressure (SPAP) (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.24-2.16 per 5 mm Hg; P = .0006) was found to be a predictor of pulmonary vasodilator response, while a European System for Cardiac Operative Risk Evaluation (EuroSCORE II) score >6.5% was a predictor of nonresponse to treatment (≤6.5% vs >6.5% [reference]: OR, 5.19; 95% CI, 1.84-14.66; P = .002). Severity of PH was associated with a positive response to treatment, where a higher proportion of responders had MPAP values >30 mm Hg (42.4% responders vs 24.1% nonresponders; P = .0237) and SPAP values >55 mm Hg (17.2% vs 3.4%; P = .0037). Easier separation from CPB was also associated with response to iE&iM treatment (69.7% vs 58.6%; P = .0181). A higher proportion of nonresponders had a very difficult separation from CPB and required intravenous inotropic drug support compared to responders, for whom easy separation from CPB was more frequent. Use of intravenous inotropes after CPB was lower in responders to treatment (8.1% vs 27.6%; P = .0052). CONCLUSIONS A positive pulmonary vasodilator response to treatment with a combination of iE&iM before initiation of CPB was observed in 77% of patients. Higher baseline SPAP was an independent predictor of pulmonary vasodilator response, while EuroSCORE II >6.5% was a predictor of nonresponse to treatment.
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Affiliation(s)
- Mahsa Elmi-Sarabi
- From the Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Stéphanie Jarry
- From the Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Etienne J Couture
- Department of Anesthesiology, Department of Medicine, Division of Intensive Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec, Canada
| | - François Haddad
- Department of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Jennifer Cogan
- From the Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Andrew J Sweatt
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, California
| | - Nicolas Rousseau-Saine
- From the Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - William Beaubien-Souligny
- Division of Nephrology, Centre Hospitalier de l'Université de Montréal (CHUM) and Innovation Hub, Research Centre CHUM, Montreal, Quebec, Canada
| | - Annik Fortier
- Department of Statistics, Montreal Health Innovations Coordinating Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - André Y Denault
- From the Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.,Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
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21
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Case Report: A Rare Manifestation of Pulmonary Arterial Hypertension in Ankylosing Spondylitis. J Pers Med 2022; 13:jpm13010062. [PMID: 36675723 PMCID: PMC9863341 DOI: 10.3390/jpm13010062] [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: 11/29/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 12/29/2022] Open
Abstract
Ankylosing spondylitis (AS) is an inflammatory disease that involves the axial skeleton and can present with extra-articular manifestations. However, there are scarce reports describing the link between AS and pulmonary arterial hypertension (PAH). Herein, we report on a 58-year-old man with a history of AS for 32 years who developed PAH as confirmed by echocardiography and right cardiac catheterization. To our knowledge, this is the first case of AS associated with PAH 32 years after the AS diagnosis with a detailed clinical description. We are recommended that physicians should be aware of this rare comorbidity in AS patients. Early echocardiographic screening is necessary for symptomatic patients.
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22
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Miyamoto J, Ohno Y, Kamioka N, Ikari Y, Otsuka T, Tada N, Naganuma T, Yamawaki M, Yamanaka F, Shirai S, Mizutani K, Tabata M, Ueno H, Takagi K, Watanabe Y, Yamamoto M, Hayashida K. Impact of Periprocedural Pulmonary Hypertension on Outcomes After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2022; 80:1601-1613. [DOI: 10.1016/j.jacc.2022.08.757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/02/2022] [Accepted: 08/10/2022] [Indexed: 11/05/2022]
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23
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Held M, Weiner S, Walthelm J, Joa F, Hoffmann J, Güder G, Pfeuffer-Jovic E. [Functional characterization of patients with isolated post-capillary or combined post-capillary and pre-capillary pulmonary hypertension]. Pneumologie 2022; 76:689-696. [PMID: 36257308 DOI: 10.1055/a-1916-1431] [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: 06/16/2023]
Abstract
BACKGROUND The World Conference on PH recommended differentiation of isolated postcapillary (Ipc) and combined post- and precapillary (Cpc) PH according to pulmonary vascular resistance alone. The aim of this study was the haemodynamic and functional characterization of patients diagnosed IpcPH and CpcPH according to the current recommendation of the latest World Symposium on Pulmonary Hypertension (PH) with an exploratory data analysis. METHODS We evaluated all consecutive patients presenting at the PH outpatient clinic of Mission Medical Hospital from 2008-2015. All received a complete diagnostic work-up according to the guidelines. We analyzed data of patients with mPAP ≥ 25 mmHg and pulmonary capillary wedge pressure (PCWP > 15 mmHg. We compared anthropometric, hemodynamic and functional data of six-minute walking test (6 MWT), cardiopulmonary exercise testing (CPET) and echocardiography of patients with IpcPH and CpcPH. RESULTS Out of 726 patients 58 showed a postcapillary PH: IpcPH: n = 20; CpcPH: n = 38. Patients with IpcPH had a significantly lower mPAP and PVR than patients with CpcPH. Cardiac index was lower in the Cpc-PH group compared to the IpcPH group. Functional capacity did not differ. CpcPH patients showed a higher right/left atrial area (RA/LA)-ratio. DISCUSSION AND CONCLUSION Although CpcPH patients showed higher values of mPAP and PVR functional capacity was not worse than in patients with IpcPH. In patients with PH due to left heart disease an elevated RA/LA ratio may indicate CpcPH and invasive diagnostic work-up should be considered.
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Affiliation(s)
- Matthias Held
- Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Standort Missioklinik, Klinikum Würzburg Mitte gGmbH
| | - Simon Weiner
- Institut für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Würzburg
| | - Johanna Walthelm
- Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Standort Missioklinik, Klinikum Würzburg Mitte gGmbH
| | - Franziska Joa
- Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Standort Missioklinik, Klinikum Würzburg Mitte gGmbH
| | - Jörg Hoffmann
- Klinik für Thorax-, Herz- und Thorakale Gefäßchirurgie, Universitätsklinikum Würzburg
| | - Gülmisal Güder
- Medizinische Klinik und Poliklinik I, Schwerpunkt Kardiologie, Universitätsklinikum Würzburg
| | - Elena Pfeuffer-Jovic
- Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Standort Missioklinik, Klinikum Würzburg Mitte gGmbH
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24
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Iliuta L, Rac-Albu M, Rac-Albu ME, Andronesi A. Impact of Pulmonary Hypertension on Mortality after Surgery for Aortic Stenosis. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1231. [PMID: 36143909 PMCID: PMC9502966 DOI: 10.3390/medicina58091231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 11/23/2022]
Abstract
Background and Objectives: The prognosis of patients with aortic stenosis (AS) adding pulmonary hypertension (PHT) is worse than in those with normal pulmonary artery pressure (PAP), and there are few results reported for the association between PHT and adverse outcomes of AS. We aimed to determine the predictive factors for the development of PHT in patients with surgical AS and to identify those factors that may predict the surgical prognosis. We aimed to identify the independent predictors for PHT regression at 2 years after surgery. Additionally, we tried to evaluate the involvement of PHT as an additional perioperative risk factor in patients with AS undergoing surgical aortic valve replacement (AVR). Materials and Methods: We carried out a two-year prospective study on 340 patients with AS undergoing surgical AVR. Results: The independent predictors for the occurrence of PHT in patients with surgical AS were: age > 75 years (RR = 6, p = 0.001), a restrictive left ventricle diastolic filling pattern (LVDFP) (RR = 9, p = 0.001) and associated moderate mitral regurgitation (MR) (RR = 9, p = 0.0001). The presence of severe PHT increased by 7.6 times the early postoperative risk of death, regardless of the presence of other parameters. The independent predictors for early postoperative mortality were: severe PHT, restrictive left ventricle diastolic pattern, age > 75 years, interventricular septum (IVS) thickness >18 mm and the presence of comorbidities. Conclusions: The presence of a severe PHT in patients with AS undergoing surgical AVR is associated with an early postoperative increased mortality rate. The mean PAP is a more reliable parameter for prognosis appreciation than the LV systolic function.
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Affiliation(s)
- Luminita Iliuta
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Cardioclass Clinic for Cardiovascular Disease, 031125 Bucharest, Romania
| | - Marius Rac-Albu
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Cardioclass Clinic for Cardiovascular Disease, 031125 Bucharest, Romania
| | - Madalina-Elena Rac-Albu
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
| | - Andreea Andronesi
- Nephrology Department, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
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Pahlavani HA. Exercise-induced signaling pathways to counteracting cardiac apoptotic processes. Front Cell Dev Biol 2022; 10:950927. [PMID: 36036015 PMCID: PMC9403089 DOI: 10.3389/fcell.2022.950927] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/15/2022] [Indexed: 01/15/2023] Open
Abstract
Cardiovascular diseases are the most common cause of death in the world. One of the major causes of cardiac death is excessive apoptosis. However, multiple pathways through moderate exercise can reduce myocardial apoptosis. After moderate exercise, the expression of anti-apoptotic proteins such as IGF-1, IGF-1R, p-PI3K, p-Akt, ERK-1/2, SIRT3, PGC-1α, and Bcl-2 increases in the heart. While apoptotic proteins such as PTEN, PHLPP-1, GSK-3, JNK, P38MAPK, and FOXO are reduced in the heart. Exercise-induced mechanical stress activates the β and α5 integrins and subsequently, focal adhesion kinase phosphorylation activates the Akt/mTORC1 and ERK-1/2 pathways, leading to an anti-apoptotic response. One of the reasons for the decrease in exercise-induced apoptosis is the decrease in Fas-ligand protein, Fas-death receptor, TNF-α receptor, Fas-associated death domain (FADD), caspase-8, and caspase-3. In addition, after exercise mitochondrial-dependent apoptotic factors such as Bid, t-Bid, Bad, p-Bad, Bak, cytochrome c, and caspase-9 are reduced. These changes lead to a reduction in oxidative damage, a reduction in infarct size, a reduction in cardiac apoptosis, and an increase in myocardial function. After exercising in the heart, the levels of RhoA, ROCK1, Rac1, and ROCK2 decrease, while the levels of PKCε, PKCδ, and PKCɑ are activated to regulate calcium and prevent mPTP perforation. Exercise has an anti-apoptotic effect on heart failure by increasing the PKA-Akt-eNOS and FSTL1-USP10-Notch1 pathways, reducing the negative effects of CaMKIIδ, and increasing the calcineurin/NFAT pathway. Exercise plays a protective role in the heart by increasing HSP20, HSP27, HSP40, HSP70, HSP72, and HSP90 along with increasing JAK2 and STAT3 phosphorylation. However, research on exercise and factors such as Pim-1, Notch, and FAK in cardiac apoptosis is scarce, so further research is needed. Future research is recommended to discover more anti-apoptotic pathways. It is also recommended to study the synergistic effect of exercise with gene therapy, dietary supplements, and cell therapy for future research.
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Jorairahmadi S, Javaherforooshzadeh F, Babazadeh M, Gholizadeh B, Bakhtiari N. Comparison of Nebulized Versus Intravenous Milrinone on Reducing Pulmonary Arterial Pressure in Patients with Pulmonary Hypertension Candidate for Open-cardiac Surgery: A Double-Blind Randomized Clinical Trial. Anesth Pain Med 2022; 12:e122994. [PMID: 36818483 PMCID: PMC9923341 DOI: 10.5812/aapm-122994] [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: 02/19/2022] [Revised: 06/06/2022] [Accepted: 07/02/2022] [Indexed: 11/16/2022] Open
Abstract
Background Regardless of the cause, pulmonary hypertension can increase patient complications and mortality. This study compared the effect of nebulized versus intravenous (IV) milrinone on reducing pulmonary arterial pressure in patients with pulmonary hypertension candidates for open-cardiac surgery. Methods This double-blind, randomized clinical trial was performed on 32 patients undergoing elective on-pump cardiac surgery during January 2021-January 2022 in the Cardiac Operating Room of Golestan Hospital, Ahvaz, Iran. Patients were randomly divided into test groups nebulize milrinone (N = 16) and IV milrinone (N = 16). The medication was administered after the cross-clamp of the aorta opening. The outcome variables included hemodynamic data, cardiac output, cardiac index, stroke volume, mean arterial pressure (MAP), central venous pressure, mean pulmonary artery pressure (mPAP), systemic vascular resistance, pulmonary vascular resistance, MAP/mPAP ratio, time until extubation, duration of hospitalization in the Intensive Care Unit (ICU), and duration of hospital stay. Results In the nebulized group, MAP and MAP/mPAP were significantly higher than in the IV milrinone group (P = 0.09 and P < 0.0001, respectively). The time of extubation (P = 0.001), duration of hospitalization in the ICU (P = 0.009), and duration of hospital stay (P = 0.026) in the nebulized milrinone group were significantly shorter than in the IV milrinone group. Conclusions Nebulized milrinone administration before weaning off cardiopulmonary bypass (CPB) can be accelerated and facilitate weaning off CPB. Moreover, despite maintaining MAP, nebulized milrinone significantly reduces mPAP. According to the results of this study, nebulized milrinone is recommended in patients undergoing cardiac surgery with pulmonary hypertension.
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Affiliation(s)
- Sara Jorairahmadi
- Department of Anesthesiology, Faculty of Medicine, Ahvaz Jundishapur University of Medical Science, Ahvaz, Iran
| | - Fatemeh Javaherforooshzadeh
- Department of Anesthesiology, Faculty of Medicine, Ahvaz Jundishapur University of Medical Science, Ahvaz, Iran
- Corresponding Author: Department of Anesthesiology, Faculty of Medicine, Ahvaz Jundishapur University of Medical Science, Ahvaz, Iran.
| | - Marziyeh Babazadeh
- Department of Biochemistry, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
- Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Behnam Gholizadeh
- Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Atherosclerosis Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Nima Bakhtiari
- Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Mandurino-Mirizzi A, Munafò A, Raineri C, Magrini G, Frassica R, Arzuffi L, Scelsi L, Turco A, Ferlini M, Gazzoli F, Ferrario M, Ghio S, Oltrona-Visconti L, Crimi G. Response to acute vasodilator challenge and haemodynamic modifications after MitraClip in patients with functional mitral regurgitation and pulmonary hypertension. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:464-469. [PMID: 35524735 PMCID: PMC9459870 DOI: 10.1093/ehjacc/zuac053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 11/17/2022]
Abstract
The effectiveness of transcatheter edge-to-edge repair (TEER) in patients with functional mitral regurgitation (FMR) and pulmonary hypertension (PH) is still debated and pre-procedural predictors of haemodynamic improvement after TEER in this setting are currently unknown. We investigated whether normalization of pulmonary artery wedge pressure (PAWP) in response to sodium nitroprusside (SNP) during baseline right heart catheterization might be predictive of a favourable haemodynamic response to MitraClip in patients with FMR and PH. Among 22 patients enrolled, 13 had a positive response to SNP (responders), nine were non-responders. At 6-months follow-up, responders showed a 33% reduction in PAWP and a 25% reduction in mean pulmonary artery pressure (PAP) (P = 0.002 and 0.004, respectively); no significant change occurred in non-responders. In patients with FMR and PH, pre-procedural vasodilator challenge with SNP may help define patients who may have haemodynamic improvement after TEER.
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Affiliation(s)
| | - Andrea Munafò
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 1, 27100 Pavia, Italy
- University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Claudia Raineri
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 1, 27100 Pavia, Italy
| | - Giulia Magrini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 1, 27100 Pavia, Italy
| | - Romina Frassica
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 1, 27100 Pavia, Italy
| | - Luca Arzuffi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 1, 27100 Pavia, Italy
- University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Laura Scelsi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 1, 27100 Pavia, Italy
| | - Annalisa Turco
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 1, 27100 Pavia, Italy
| | - Marco Ferlini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 1, 27100 Pavia, Italy
| | - Fabrizio Gazzoli
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 1, 27100 Pavia, Italy
| | - Maurizio Ferrario
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 1, 27100 Pavia, Italy
| | - Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 1, 27100 Pavia, Italy
| | - Luigi Oltrona-Visconti
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 1, 27100 Pavia, Italy
| | - Gabriele Crimi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 1, 27100 Pavia, Italy
- Interventional Cardiology Unit, Cardio-Thoraco Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Genova, Italy
- IRCCS Italian Cardiovascular Network & Department of Internal Medicine, University of Genova, Genova, Italy
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McGlothlin D, Granton J, Klepetko W, Beghetti M, Rosenzweig EB, Corris P, Horn E, Kanwar M, McRae K, Roman A, Tedford R, Badagliacca R, Bartolome S, Benza R, Caccamo M, Cogswell R, Dewachter C, Donahoe L, Fadel E, Farber HW, Feinstein J, Franco V, Frantz R, Gatzoulis M, Hwa (Anne) Goh C, Guazzi M, Hansmann G, Hastings S, Heerdt P, Hemnes A, Herpain A, Hsu CH, Kerr K, Kolaitis N, Kukreja J, Madani M, McCluskey S, McCulloch M, Moser B, Navaratnam M, Radegran G, Reimer C, Savale L, Shlobin O, Svetlichnaya J, Swetz K, Tashjian J, Thenappan T, Vizza CD, West S, Zuckerman W, Zuckermann A, De Marco T. ISHLT CONSENSUS STATEMENT: Peri-operative Management of Patients with Pulmonary Hypertension and Right Heart Failure Undergoing Surgery. J Heart Lung Transplant 2022; 41:1135-1194. [DOI: 10.1016/j.healun.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 10/17/2022] Open
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Impact of Pulmonary Hypertension on Outcomes in Patients With Mitral Annular Calcium and Associated Mitral Valve Dysfunction. Am J Cardiol 2022; 167:76-82. [PMID: 34991846 DOI: 10.1016/j.amjcard.2021.11.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/23/2021] [Accepted: 11/29/2021] [Indexed: 12/18/2022]
Abstract
The prevalence of mitral annular calcium (MAC) is increasing in our aging population. However, data regarding prognostication in MAC-related mitral valve (MV) disease remain limited. This retrospective observational study aims to explore the prognostic impact of systolic pulmonary artery pressure (SPAP) in MAC-related MV dysfunction and define its determinants. We identified 4,384 patients (mean age 78 ± 11 years and 69% female) with MAC-related MV dysfunction (documented transmitral gradient ≥3 mm Hg) from a large institutional echocardiographic database between 2001 and 2019. In Cox regression analysis, higher SPAP strongly associated with all-cause mortality, independent of cardiovascular risk factors and indices of MV dysfunction (adjusted hazard ratio 1.22 per 10 mm Hg SPAP increase, 95% confidence interval 1.17 to 1.27). Patients with SPAP ≥50 mm Hg had significantly higher mortality compared with SPAP <50 mm Hg (log-rank p <0.001), a finding that was consistent across different transmitral gradient subgroups (≤5, 5 to 10, and ≥10 mm Hg). Independent determinants of SPAP included the mean transmitral gradient, mitral regurgitation severity, left ventricular ejection fraction, and ≥moderate aortic stenosis (adjusted p <0.05), and atrial fibrillation and left atrial dimension. The impact of concomitant mitral regurgitation on SPAP decreased at higher transmitral gradients and was no longer significant at gradients ≥10 mm Hg (p = 0.100). In conclusion, SPAP strongly associates with mortality in MAC, independent of cardiovascular risk factors and indices of MAC-related MV dysfunction. These findings suggest an incremental role for SPAP in the risk stratification and prognostication in this increasingly prevalent condition with expanding the scope of possible interventions.
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Extramitral Valvular Cardiac Involvement in Patients With Significant Secondary Mitral Regurgitation. Am J Cardiol 2022; 162:143-149. [PMID: 34702554 DOI: 10.1016/j.amjcard.2021.09.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/14/2021] [Accepted: 09/17/2021] [Indexed: 01/12/2023]
Abstract
Patients with secondary mitral regurgitation (SMR) often have extramitral valve cardiac involvement, which can influence the prognosis. SMR can be defined according to groups of extramitral valve cardiac involvement. The prognostic implications of such groups in patients with moderate and severe SMR (significant SMR) are unknown. A total of 325 patients with significant SMR were classified according to the extent of cardiac involvement on echocardiography: left ventricular involvement (group 1), left atrial involvement (group 2), tricuspid valve and pulmonary artery vasculature involvement (group 3), or right ventricular involvement (group 4). The primary end point was all-cause mortality. The prevalence of each cardiac involvement group was 17% in group 1, 12% in group 2, 23% in group 3%, and 48% in group 4. Group 3 and group 4 were independently associated with all-cause mortality (hazard ratio 1.794, 95% confidence interval 1.067 to 3.015, p = 0.027 and hazard ratio 1.857, 95% confidence interval 1.145 to 3.012, p = 0.012, respectively). In conclusion, progressive extramitral valve cardiac involvement (group 3 and group 4) was independently associated with all-cause mortality in patients with significant SMR.
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Abdelghani MS, Sardar S, Hamada AS. Asymptomatic Severe Aortic Stenosis: Contemporary Evaluation and Management. Heart Views 2022; 23:16-21. [PMID: 35757454 PMCID: PMC9231543 DOI: 10.4103/heartviews.heartviews_34_22] [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: 03/03/2022] [Accepted: 04/03/2022] [Indexed: 11/17/2022] Open
Abstract
Aortic stenosis (AS) is the most prevalent valvular heart disease in developed countries and most prevalent in the elderly. According to the current guidelines, intervention is recommended in symptomatic severe AS; however, in asymptomatic patients, aortic valve replacement (AVR) is considered when symptoms appear or the left ventricular dysfunction occurs, but the evidence supports these indications are poor. The optimal timing and modality of intervention in asymptomatic severe AS (ASAS) remain controversial. Earlier AVR in certain scenarios has been increasingly supported by some groups before subclinical irreversible myocardial damage occurs. In addition, the continuous advancement of percutaneous and surgical approaches where associated with a substantial decrease in mortality and perioperative complications which made many authors advocate for early intervention in those patients. Our review highlights the contemporary evaluation and management of ASAS and summarizes the current scientific evidence regarding optimal timing for intervention and indications for early AVR in such patients.
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Affiliation(s)
| | - Sundus Sardar
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
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Popolo Rubbio A, Testa L, Granata G, Salvatore T, De Marco F, Casenghi M, Guerrini M, Oliva OA, Stefanini E, Barletta M, Sisinni A, Poletti E, Zannoni J, Gorla R, Brambilla N, Tusa M, Bedogni F. Prognostic significance of right ventricle to pulmonary artery coupling in patients with mitral regurgitation treated with the MitraClip system. Catheter Cardiovasc Interv 2021; 99:1277-1286. [PMID: 34939726 DOI: 10.1002/ccd.30044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/10/2021] [Accepted: 11/27/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To evaluate the prognostic impact of baseline tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio, as an expression of the right ventricle-pulmonary artery (RV-PA) coupling, in patients with mitral regurgitation (MR) treated with the MitraClip. BACKGROUND Impaired RV to PA coupling is considered a marker of RV dysfunction. METHODS From February 2016 to February 2020, a total of 165 patients were evaluated and stratified in two groups according to a prespecified value of TAPSE/PASP ratio ≤ 0.36. RESULTS The median patients' age was 79 (men: 62.4%). Sixty-three patients (38.1%) presented TAPSE/PASP ≤ 0.36 and were then compared with patients with TAPSE/PASP > 0.36. Functional MR etiology was more frequent in TAPSE/PASP ≤ 0.36 (71.4%; p = 0.046). Acute technical success was achieved in 92.7% of the population, without any significant difference between the two groups of study and with sustained results at 30-day (device success: 85.5%; procedural success: 84.8%). On multivariate Cox regression analysis, after correction for body mass index, chronic kidney disease and left ventricle ejection fraction ≥30% but <50%, TAPSE/PASP ≤ 0.36 remained a sustained predictor of mortality and hospitalization for heart failure at one year after MitraClip (hazard ratio: 3.87; 95% confidence interval: 1.83-8.22; p ≤ 0.001). Kaplan-Meier all-cause mortality and heart failure hospitalization rates at one year were consequently higher in patients with TAPSE/PASP ≤ 0.36 (39.4% vs. 14.8%; log-rank p ≤ 0.001). CONCLUSION Baseline TAPSE/PASP ratio seems independently associated with all-cause mortality and heart failure hospitalization after MitraClip both in functional and degenerative MR.
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Affiliation(s)
- Antonio Popolo Rubbio
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Luca Testa
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Giuseppina Granata
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Tanya Salvatore
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Federico De Marco
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Matteo Casenghi
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marco Guerrini
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Omar A Oliva
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Elisa Stefanini
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marta Barletta
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Antonio Sisinni
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Enrico Poletti
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Jessica Zannoni
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Riccardo Gorla
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Nedy Brambilla
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Maurizio Tusa
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Francesco Bedogni
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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Held M, Weiner S, Walthelm J, Joa F, Hoffmann J, Güder G, Pfeuffer-Jovic E. [Functional characterization of patients with isolated post-capillary or combined post-capillary and pre-capillary pulmonary hypertension]. Dtsch Med Wochenschr 2021; 146:e88-e94. [PMID: 34670324 PMCID: PMC8550820 DOI: 10.1055/a-1555-0345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The World Conference on PH recommended differentiation of isolated postcapillary (Ipc) and combined post- and precapillary (Cpc) PH according to pulmonary vascular resistance alone. The aim of this study was the haemodynamic and functional characterization of patients diagnosed IpcPH and CpcPH according to the current recommendation of the latest World Symposium on Pulmonary Hypertension (PH) with an exploratory data analysis. METHODS We evaluated all consecutive patients presenting at the PH outpatient clinic of Mission Medical Hospital from 2008-2015. All received a complete diagnostic work-up according to the guidelines. We analyzed data of patients with mPAP≥ 25 mmHg and pulmonary capillary wedge pressure (PCWP) > 15 mmHg. We compared anthropometric, hemodynamic and functional data of six-minute walking test (6 MWT), cardiopulmonary exercise testing (CPET) and echocardiography of patients with IpcPH and CpcPH. RESULTS Out of 726 patients 58 showed a postcapillary PH: IpcPH: n = 20; CpcPH: n = 38. Patients with IpcPH had a significantly lower mPAP and PVR than patients with CpcPH. Cardiac index was lower in the Cpc-PH group compared to the IpcPH group. Functional capacity did not differ. CpcPH patients showed a higher right/left atrial area (RA/LA)-ratio. DISCUSSION AND CONCLUSION Although CpcPH patients showed higher values of mPAP and PVR functional capacity was not worse than in patients with IpcPH. In patients with PH due to left heart disease an elevated RA/LA ratio may indicate CpcPH and invasive diagnostic work-up should be considered.
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Affiliation(s)
- Matthias Held
- Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Standort Missioklinik, Klinikum Würzburg Mitte gGmbH
| | - Simon Weiner
- Institut für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Würzburg
| | - Johanna Walthelm
- Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Standort Missioklinik, Klinikum Würzburg Mitte gGmbH
| | - Franziska Joa
- Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Standort Missioklinik, Klinikum Würzburg Mitte gGmbH
| | - Jörg Hoffmann
- Klinik für Thorax-, Herz- und Thorakale Gefäßchirurgie, Universitätsklinikum Würzburg
| | - Gülmisal Güder
- Medizinische Klinik und Poliklinik I, Schwerpunkt Kardiologie, Universitätsklinikum Würzburg
| | - Elena Pfeuffer-Jovic
- Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Standort Missioklinik, Klinikum Würzburg Mitte gGmbH
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Zou T, Chen Q, Zhang L, Chen C, Ling Y, Liu G, Wang S, Pang Y, Xu Y, Cheng K, Zhou D, Zhu W, Ge J. Pulmonary artery pressure is associated with mid-term major adverse cardiovascular events and postprocedure pericardial effusion in atrial fibrillation patients undergoing left atrial appendage occlusion. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1324. [PMID: 34532461 PMCID: PMC8422141 DOI: 10.21037/atm-21-3561] [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: 06/17/2021] [Accepted: 08/01/2021] [Indexed: 11/06/2022]
Abstract
Background Patients with nonvalvular atrial fibrillation (NVAF) undergoing left atrial appendage occlusion (LAAO) are at high risk of stroke or bleeding. However, risk factors for their adverse cardiovascular events remain largely unknown. Pulmonary hypertension has been shown to be related to poor prognosis in many heart diseases. In this study, we determined whether elevated pulmonary artery systolic pressure (PASP) is associated with postprocedure adverse events and major adverse cardiovascular events (MACE) in these patients. Methods From June 2017 and December 2019, 530 consecutive patients with NAVF at high risk of stroke or bleeding who undergone LAAO were retrospectively enrolled in our study. The preprocecure PASP was obtained by transthoracic echocardiography using the simplified Bernoulli's equation. Patients were followed-up through clinic visits or over the phone at discharge at 1-3 months, 6 months, and annually thereafter. The median follow-up time was 12 months, and clinical data were analyzed. MACE was defined as myocardial infarction, definite heart failure, stroke, or all-cause death. The outcome of postprocedure pericardial effusion included in-hospital pericardial effusion and pericardial effusion detected after discharge. Results Univariate analyses indicated that patients who had MACE tended to have elevated PASP (P=0.005). After dividing the cohort according to the cut-off value of PASP, Kaplan-Meier curves indicated that patients with PASP ≥39.5 mmHg had a higher risk of MACE (P=0.007) and heart failure hospitalization (P=0.005) compared to patients whose PASP <39.5 mmHg. Cox regression analysis showed that PASP was a predominant risk factor of MACE (HR =2.337, 95% CI, 1.207-4.526, P=0.012) and heart failure hospitalization (HR =3.701, 95% CI, 1.118-12.251, P=0.032). Furthermore, the PASP cut-off added incremental discriminatory capacity to the MACE risk model of this cohort. In addition, logistic regression showed that PASP had as a significant association with postprocedure pericardial effusion (OR =1.061, P=0.032). Conclusions Elevated PASP was associated with postprocedure pericardial effusion and mid-term MACEs in patients with atrial fibrillation (AF) undergoing LAAO.
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Affiliation(s)
- Tian Zou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China
| | - Qingxing Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China
| | - Lei Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China
| | - Chaofeng Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China
| | - Yunlong Ling
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China
| | - Guijian Liu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China
| | - Sunying Wang
- Department of Cardiology, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Yang Pang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China
| | - Ye Xu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China
| | - Kuan Cheng
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China
| | - Daxin Zhou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China
| | - Wenqing Zhu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China
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Gopal A, Sharma T, Calkins JB. Safety of Phosphodiesterase-5 Inhibitors in Valvular Heart Disease. J Cardiovasc Pharmacol 2021; 78:372-376. [PMID: 34074904 DOI: 10.1097/fjc.0000000000001071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/16/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Erectile dysfunction is a common entity in clinical practice. Primary erectile dysfunction, not related to vasculopathy or psychiatric disorder, can be readily treated with phosphodiesterase inhibitors. These drugs have many physiologic effects that can alter a patient's hemodynamic profile considerably, especially in the presence of concomitant structural heart disease, specifically valvular heart disease. Although some contraindications to the use of PDE5 inhibitors in patients with cardiovascular disease are defined, the effect of these drugs in the presence of valvular heart disease is not well documented. The purpose of this review is to analyze the data regarding the safety of PDE5 inhibitors in patients with valvular heart disease.
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Affiliation(s)
- Aaron Gopal
- Division of Cardiology, Medical College of Georgia at Augusta University
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Ferreira de Sales I, Lodi-Junqueira L, Rafael Sant'Anna Athayde G, Eugenia Alcici M, Costa Diamantino T, Campos Barbosa E Silva L, Vargas Botinha Macedo F, Leal Fraga C, Camargos Mucelli Spalaor B, Victor Silva Valente P, Rodrigues Soares J, C Tan T, Antonio de Magalhães Esteves W, Pereira Nunes MC. Pulmonary artery pressure response to percutaneous mitral valvuloplasty: Associated factors and clinical implications. Catheter Cardiovasc Interv 2021; 99:915-923. [PMID: 34415669 DOI: 10.1002/ccd.29926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 08/08/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH) is a marker of poor outcome in mitral stenosis (MS), which improves after percutaneous mitral valvuloplasty (PMV). However, mechanical interventions for relief of valve obstruction often but not always reduce pulmonary pressures. This study aimed to assess the parameters associated with abnormal pulmonary artery pressure (PAP) response immediately after a successful PMV, and also its impact on long-term outcome. METHODS A total of 181 patients undergoing PMV for rheumatic MS were prospectively enrolled. Invasive hemodynamic and echocardiographic measures were examined in all patients. Abnormal PAP response was defined as the mean PAP (mPAP) values unchanged at the end of the procedure. Long-term outcome was a composite endpoint of death, mitral valve replacement, repeat PMV, new onset of atrial fibrillation (AF), or stroke. RESULTS The mean age was 44.1 ± 12.6 years, and 157 patients were women (86.7%). In the overall population, mPAP decreased from 33.4 ± 13.1 mmHg pre to 27.6 ± 9.8 mmHg post (p < 0.001). Following PMV, 52 patients (28.7%) did not have any reduction of mPAP immediately after the PMV. Multivariable analysis adjusting for baseline values of PAP and mitral valve area revealed that AF (Odds ratio [OR] 2.7, 95% [confidence interval] CI 1.3 to 6.7), maximum mitral valve leaflets displacement (OR 0.8, 95% CI 0.7 to 0.9), and post-procedural left ventricular compliance (OR 0.7, 95% CI 0.5 to 0.9) were predictors of a lack of improvement in mPAP. During a median follow-up of 4.4 years, the endpoint was reached in 56 patients (31%). The pulmonary pressure response to PMV was not an independent predictor of long-term events. CONCLUSIONS In patients with MS undergoing PMV, pulmonary pressures may not reduce immediately after the procedure, despite adequate opening of the valve. Abnormal PAP response can be predicted from baseline clinical and valvular characteristics as well as post-procedural left ventricular compliance. The lack of any immediate reduction in mPAP is not associated with long-term adverse outcomes.
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Affiliation(s)
- Igor Ferreira de Sales
- Postgraduate Course of Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Hospital das Clinicas, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Lucas Lodi-Junqueira
- Hospital das Clinicas, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Guilherme Rafael Sant'Anna Athayde
- Postgraduate Course of Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Hospital das Clinicas, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Marta Eugenia Alcici
- Postgraduate Course of Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Hospital das Clinicas, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Tatiana Costa Diamantino
- Hospital das Clinicas, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Clara Leal Fraga
- Hospital das Clinicas, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Juliana Rodrigues Soares
- Postgraduate Course of Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Hospital das Clinicas, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, University of Western Sydney, Sydney, New South Wales, Australia
| | | | - Maria Carmo Pereira Nunes
- Postgraduate Course of Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Hospital das Clinicas, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Izumo M, Kuwata S, Ishibashi Y, Suzuki T, Ohara H, Watanabe M, Sato Y, Nishikawa H, Okuyama K, Kamijima R, Takai M, Kou S, Harada T, Akashi YJ. Prognostic impact of transcatheter mitral valve repair in patients with exercise-induced secondary mitral regurgitation. Eur Heart J Cardiovasc Imaging 2021; 22:530-538. [PMID: 32856088 DOI: 10.1093/ehjci/jeaa200] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 06/20/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS Although exercise-induced secondary mitral regurgitation (MR) is known to have a poor prognosis, the therapeutic strategy towards this condition remains to be investigated. In the present study, we aimed to investigate the prognostic impact of transcatheter mitral valve repair (TMVr) using the MitraClip in patients with exercise-induced secondary MR. METHODS AND RESULTS Of the 200 consecutive patients with secondary MR who underwent exercise stress echocardiography, 46 (23%) that presented with exercise-induced secondary MR [i.e. increase in effective regurgitant orifice area (EROA) of ≥ 0.13 cm2] were enrolled in the present investigation. The composite endpoints of all-cause mortality and hospitalization for heart failure were evaluated. Of the 46 patients included in the current cohort, 19 (41%) underwent TMVr and 27 (59%) were medically managed (control group). Although the TMVr group tended to present with a greater EROA at rest (0.26 ± 0.10 vs. 0.20 ± 0.08 cm2, P = 0.047), there were no differences in the EROA changes during exercise between the two groups (0.18 ± 0.10 vs. 0.18 ± 0.04 cm2, P = 0.940). While the TMVr group reported a higher event-free survival rate after the 13-month follow-up period (log-rank P = 0.017), the Cox proportional-hazard analysis suggested the TMVr to be associated with clinical outcomes (hazard ratio: 0.419, P = 0.044). CONCLUSION As opposed to the medical management, TMVr treatment was associated with a lower risk of composite endpoints in patients with exercise-induced secondary MR. Exercise stress echocardiography is considered to have played an important role in decision-making for secondary MR.
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Affiliation(s)
- Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Shingo Kuwata
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Yuki Ishibashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Tomomi Suzuki
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Hiroshi Ohara
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Mika Watanabe
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Yukio Sato
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Haruka Nishikawa
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Kazuaki Okuyama
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Ryo Kamijima
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Manabu Takai
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Seisyo Kou
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Tomoo Harada
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan
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Cosyns B, Magne J. Exercise Systolic Pulmonary Arterial Pressure in Asymptomatic Mitral Regurgitation: Back to the Future. J Am Soc Echocardiogr 2021; 34:941-943. [PMID: 34186169 DOI: 10.1016/j.echo.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 06/22/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Bernard Cosyns
- Cardiology Department, Centrum voor hart en vaatziekten, Universitair Ziekenhuis Brussel, Free University of Brussels, Brussels, Belgium.
| | - Julien Magne
- CHU Limoges, Hôpital Dupuytren, Service Cardiologie; and INSERM 1094, Faculté de médecine de Limoges, Limoges, France
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Lazea C, Bucerzan S, Al-Khzouz C, Zimmermann A, Vesa ȘC, Nașcu I, Creț V, Crișan M, Asăvoaie C, Miclea D, Grigorescu-Sido P. Cardiac Manifestations in a Group of Romanian Patients with Gaucher Disease Type 1 (a Monocentric Study). Diagnostics (Basel) 2021; 11:diagnostics11060989. [PMID: 34072542 PMCID: PMC8227770 DOI: 10.3390/diagnostics11060989] [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: 04/06/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 11/17/2022] Open
Abstract
Gaucher disease (GD), one of the most common lysosomal disorders, is characterised by clinical heterogeneity. Cardiac involvement is rare and refers to pulmonary hypertension (PH), valvular abnormalities and myocardial infiltrative damage. The aim of this study was to evaluate cardiac involvement in a group of Romanian GD patients. Phenotypic and genotypic characterisation was carried out in 69 patients with GD type 1. Annual echocardiography and electrocardiography were performed to assess pulmonary pressure, morphology and function of the valves and electrocardiographic changes. Nine patients (13%) exhibited baseline echocardiographic signs suggesting PH. Mitral regurgitation was present in 33 patients (48%) and aortic regurgitation in 11 patients (16%). One patient presented aortic stenosis. Significant valvular dysfunction was diagnosed in 10% of patients. PH was associated with greater age (p < 0.001), longer time since splenectomy (p = 0.045) and longer time between clinical onset and the start of enzyme replacing therapy (p < 0.001). Electrocardiographic changes were present in five patients (7%).
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Affiliation(s)
- Cecilia Lazea
- 1st Pediatric Discipline, Mother and Child Department, “Iuliu Hațieganu” University of Medicine and Pharmacy, Clinic Pediatrics I, Emergency Pediatric Hospital, 400370 Cluj-Napoca, Romania; (S.B.); (C.A.-K.)
- Correspondence: ; Tel.: +40-744-353-764
| | - Simona Bucerzan
- 1st Pediatric Discipline, Mother and Child Department, “Iuliu Hațieganu” University of Medicine and Pharmacy, Clinic Pediatrics I, Emergency Pediatric Hospital, 400370 Cluj-Napoca, Romania; (S.B.); (C.A.-K.)
- Department of Genetic Diseases, Emergency Pediatric Hospital, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400370 Cluj-Napoca, Romania
| | - Camelia Al-Khzouz
- 1st Pediatric Discipline, Mother and Child Department, “Iuliu Hațieganu” University of Medicine and Pharmacy, Clinic Pediatrics I, Emergency Pediatric Hospital, 400370 Cluj-Napoca, Romania; (S.B.); (C.A.-K.)
- Department of Genetic Diseases, Emergency Pediatric Hospital, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400370 Cluj-Napoca, Romania
| | - Anca Zimmermann
- 1st Clinic and Polyclinic of Internal Medicine, Medical Clinic 2, Clinic of Worms, Department of Diabetology and Endocrinology, University Medical Center, 55131 Mainz, Germany;
| | - Ștefan Cristian Vesa
- Department of Pharmacology, Toxicology and Clinical Pharmacology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
| | - Ioana Nașcu
- Emergency Pediatric Hospital, 400370 Cluj-Napoca, Romania; (I.N.); (V.C.); (M.C.); (C.A.)
| | - Victoria Creț
- Emergency Pediatric Hospital, 400370 Cluj-Napoca, Romania; (I.N.); (V.C.); (M.C.); (C.A.)
| | - Mirela Crișan
- Emergency Pediatric Hospital, 400370 Cluj-Napoca, Romania; (I.N.); (V.C.); (M.C.); (C.A.)
| | - Carmen Asăvoaie
- Emergency Pediatric Hospital, 400370 Cluj-Napoca, Romania; (I.N.); (V.C.); (M.C.); (C.A.)
| | - Diana Miclea
- Department of Medical Genetics, “Iuliu Hațieganu” University of Medicine and Pharmacy, Emergency Pediatric Hospital, 400012 Cluj-Napoca, Romania;
| | - Paula Grigorescu-Sido
- Faculty of Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
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Radhoe SP, Veenis JF, Van Mieghem NM, Brugts JJ. The effect of transcatheter aortic valve implantation on pulmonary artery pressures in a patient suffering from chronic heart failure: a case report. Eur Heart J Case Rep 2021; 5:ytab112. [PMID: 34268473 PMCID: PMC8276598 DOI: 10.1093/ehjcr/ytab112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/13/2020] [Accepted: 03/10/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Pulmonary hypertension (PH) is most commonly caused by left-sided heart disease and may negatively affect the long-term prognosis and quality of life of patients with chronic heart failure (CHF). CardioMEMS (Micro-Electro-Mechanical-System) allows physicians to monitor pulmonary artery (PA) pressures remotely and optimize heart failure treatment based on haemodynamic parameters, which provides further insight into the effect of valvular interventions. CASE SUMMARY We present a case of a 61-year-old male patient with an ischaemic cardiomyopathy, poor LV function, moderate to severe mitral regurgitation, and severe aortic valve regurgitation in refractory heart failure. Right heart catheterization and CardioMEMS monitoring revealed severe pulmonary hypertension with mean PA pressures of 55 mmHg and a mean pulmonary capillary wedge pressure of 21 mmHg despite up titration of heart failure medication and sildenafil. Pulmonary and systemic causes of pulmonary hypertension were excluded. After heart team consensus, the patient underwent transcatheter aortic valve implantation (TAVI) which resulted in normalization of PA pressures and a significant improvement of functional performance. DISCUSSION To the best of our knowledge, this is the first case report describing the direct effects of TAVI on continuous PA pressures in a patient with poor LV function and severe aortic regurgitation. Elective TAVI appeared to be safe and very effective in reverting severe pulmonary hypertension. Most strikingly, drug interventions could not affect the elevated pulmonary pressures, but TAVI corrected the aortic valve insufficiency with normalization of left-sided pulmonary hypertension.
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Affiliation(s)
- Sumant P Radhoe
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center Rotterdam, Dr Molewaterplein 40, 3015GD, Rotterdam, the Netherlands
| | - Jesse F Veenis
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center Rotterdam, Dr Molewaterplein 40, 3015GD, Rotterdam, the Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center Rotterdam, Dr Molewaterplein 40, 3015GD, Rotterdam, the Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center Rotterdam, Dr Molewaterplein 40, 3015GD, Rotterdam, the Netherlands
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41
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Feng L, Gao H, Qi N, Danton M, Hill NA, Luo X. Fluid-structure interaction in a fully coupled three-dimensional mitral-atrium-pulmonary model. Biomech Model Mechanobiol 2021; 20:1267-1295. [PMID: 33770307 PMCID: PMC8298265 DOI: 10.1007/s10237-021-01444-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 03/01/2021] [Indexed: 12/17/2022]
Abstract
This paper aims to investigate detailed mechanical interactions between the pulmonary haemodynamics and left heart function in pathophysiological situations (e.g. atrial fibrillation and acute mitral regurgitation). This is achieved by developing a complex computational framework for a coupled pulmonary circulation, left atrium and mitral valve model. The left atrium and mitral valve are modelled with physiologically realistic three-dimensional geometries, fibre-reinforced hyperelastic materials and fluid–structure interaction, and the pulmonary vessels are modelled as one-dimensional network ended with structured trees, with specified vessel geometries and wall material properties. This new coupled model reveals some interesting results which could be of diagnostic values. For example, the wave propagation through the pulmonary vasculature can lead to different arrival times for the second systolic flow wave (S2 wave) among the pulmonary veins, forming vortex rings inside the left atrium. In the case of acute mitral regurgitation, the left atrium experiences an increased energy dissipation and pressure elevation. The pulmonary veins can experience increased wave intensities, reversal flow during systole and increased early-diastolic flow wave (D wave), which in turn causes an additional flow wave across the mitral valve (L wave), as well as a reversal flow at the left atrial appendage orifice. In the case of atrial fibrillation, we show that the loss of active contraction is associated with a slower flow inside the left atrial appendage and disappearances of the late-diastole atrial reversal wave (AR wave) and the first systolic wave (S1 wave) in pulmonary veins. The haemodynamic changes along the pulmonary vessel trees on different scales from microscopic vessels to the main pulmonary artery can all be captured in this model. The work promises a potential in quantifying disease progression and medical treatments of various pulmonary diseases such as the pulmonary hypertension due to a left heart dysfunction.
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Affiliation(s)
- Liuyang Feng
- School of Mathematics and Statistics, University of Glasgow, Glasgow, G12 8SQ, UK.
| | - Hao Gao
- School of Mathematics and Statistics, University of Glasgow, Glasgow, G12 8SQ, UK
| | - Nan Qi
- Institute of Marine Science and Technology, Shandong University, Shangdong, 266237, People's Republic of China
| | - Mark Danton
- Department of Cardiac Surgery, Royal Hospital for Children, Glasgow, UK
| | - Nicholas A Hill
- School of Mathematics and Statistics, University of Glasgow, Glasgow, G12 8SQ, UK
| | - Xiaoyu Luo
- School of Mathematics and Statistics, University of Glasgow, Glasgow, G12 8SQ, UK
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42
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Ben-Yehuda O, Shahim B, Chen S, Liu M, Redfors B, Hahn RT, Asch FM, Weissman NJ, Medvedofsky D, Puri R, Kapadia S, Sannino A, Grayburn P, Kar S, Lim S, Lindenfeld J, Abraham WT, Mack MJ, Stone GW. Pulmonary Hypertension in Transcatheter Mitral Valve Repair for Secondary Mitral Regurgitation: The COAPT Trial. J Am Coll Cardiol 2021; 76:2595-2606. [PMID: 33243380 DOI: 10.1016/j.jacc.2020.09.609] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/25/2020] [Accepted: 09/28/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Pulmonary hypertension worsens prognosis in patients with heart failure (HF) and secondary mitral regurgitation (SMR). OBJECTIVES This study sought to determine whether baseline pulmonary hypertension influences outcomes of transcatheter mitral valve repair (TMVr) in patients with HF with SMR. METHODS In the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial, 614 patients with HF with moderate-to-severe or severe SMR were randomized to TMVr with the MitraClip plus guideline-directed medical therapy (GDMT) (n = 302) versus GDMT alone (n = 312). Baseline pulmonary artery systolic pressure (PASP) estimated from echocardiography was categorized as substantially increased (≥50 mm Hg) versus not substantially increased (<50 mm Hg). RESULTS Among 528 patients, 184 (82 TMVr, 102 GDMT) had PASP of ≥50 mm Hg (mean: 59.1 ± 8.8 mm Hg) and 344 (171 TMVr, 173 GDMT) had PASP of <50 mm Hg (mean: 36.3 ± 8.1 mm Hg). Patients with PASP of ≥50 mm Hg had higher 2-year rates of death or HF hospitalization (HFH) compared to those with PASP of <50 mm Hg (68.8% vs. 49.1%; adjusted hazard ratio: 1.52; 95% confidence interval: 1.17 to 1.97; p = 0.002). Rates of death or HFH were reduced by TMVr versus GDMT alone, irrespective of baseline PASP (pinteraction = 0.45). TMVr reduced PASP from baseline to 30 days to a greater than GDMT alone (adjusted least squares mean: -4.0 vs. -0.9 mm Hg; p = 0.006), a change that was associated with reduced risk of death or HFH between 30 days and 2 years (adjusted hazard ratio: 0.91 per -5 mm Hg PASP; 95% confidence interval: 0.86 to 0.96; p = 0.0009). CONCLUSIONS Elevated PASP is associated with a worse prognosis in patients with HF with severe SMR. TMVr with the MitraClip reduced 30-day PASP and 2-year rates of death or HFH compared with GDMT alone, irrespective of PASP.
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Affiliation(s)
| | - Bahira Shahim
- Cardiovascular Research Foundation, New York, New York
| | - Shmuel Chen
- Cardiovascular Research Foundation, New York, New York; Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | - Mengdan Liu
- Cardiovascular Research Foundation, New York, New York
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York
| | - Rebecca T Hahn
- Cardiovascular Research Foundation, New York, New York; Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | | | | | | | | | | | | | | | - Saibal Kar
- Los Robles Regional Medical Center, Thousand Oaks, California
| | - Scott Lim
- University of Virginia, Charlottesville, Virginia
| | | | | | | | - Gregg W Stone
- Cardiovascular Research Foundation, New York, New York; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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Huang ST, Xu N, Sun KP, Chen Q, Cao H. Effect of Treprostinil on the Early Postoperative Prognosis of Patients with Severe Left Heart Valvular Disease Combined with Severe Pulmonary Hypertension. Ann Thorac Cardiovasc Surg 2021; 27:18-24. [PMID: 32493870 PMCID: PMC8043024 DOI: 10.5761/atcs.oa.20-00003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To investigate the effect of treprostinil on the early postoperative prognosis of patients with severe left heart valvular disease combined with severe pulmonary hypertension (PAH). METHODS A retrospective study including 55 patients with severe left heart valvular disease combined with severe PAH who underwent left heart valve replacement in our hospital between January 2019 and May 2019 was conducted. Patients were divided into two groups (treprostinil group and control group), and the clinical data of patients in the two groups were compared and analyzed. RESULTS Compared with the preoperative status, the mean postoperative pulmonary artery pressure (mPAP) in both groups was significantly lower. Compared with the control group, the treprostinil group had a significantly lower mPAP. Moreover, the postoperative mechanical ventilation time, intensive care unit (ICU) stay, and hospital stay of the treprostinil group were significantly shorter than those of the control group. There were no serious drug-related side effects in either group. CONCLUSIONS Treprostinil can improve the early postoperative prognosis of patients with severe left heart valvular disease combined with severe PAH undergoing prosthetic valve replacement.
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Affiliation(s)
- Shu-Ting Huang
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Ning Xu
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Kai-Peng Sun
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Qiang Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
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44
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Chen HH, Lin CH, Hsieh TY, Chen DY, Ying JC, Chao WC. Factors Associated with Incident Severe Pulmonary Arterial Hypertension in Systemic Autoimmune Rheumatic Diseases: a Nationwide Study. Rheumatology (Oxford) 2021; 60:5351-5361. [PMID: 33547781 DOI: 10.1093/rheumatology/keab118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/22/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To assess the association of severe pulmonary arterial hypertension (PAH) with particulate matter <2.5 μm (PM2.5) and clinical data in patients with systemic autoimmune rheumatic diseases (SARDs). METHODS We used the 2003-2017 nationwide data in Taiwan to identify patients with SARDs, including systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, dermatomyositis/polymyositis and primary Sjögren's syndrome. We identified 479 cases with severe PAH and selected controls matched (1:4) for age, sex, and index-year. We used conditional logistic regression analysis to determine factors associated with risks for severe PAH shown as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS We found that severe PAH was highly associated with interstitial lung disease (OR, 8.57; 95% CI, 5.52-13.32), congestive heart failure (OR, 7.62; 95% CI, 5.02-11.55), valvular heart disease (OR, 3.34; 95% CI, 2.03-5.50) and slightly associated with thyroid diseases (OR, 1.88; 95% CI, 1.18-3.00), but not the level of exposure to PM2.5. Increased risk for PAH was found in patients receiving corticosteroid (prednisolone equivalent dosage, mg/day, OR, 1.03; 95% CI, 1.01-1.05), biologics (OR, 2.18; 95% CI, 1.15-4.12) as well as immunosuppressants, including cyclosporin (OR, 2.17; 95% CI, 1.31-3.59), azathioprine (OR, 1.96; 95% CI, 1.48-2.61), cyclophosphamide (OR, 2.01; 95% CI, 1.30-3.11) and mycophenolate mofetil/mycophenolic acid (OR, 2.42; 95% CI, 1.37-4.27), and those with the highest level of insured amount (reference, lowest level; OR, 0.53; 95% CI, 0.34-0.83). CONCLUSION The population-based study identified risks for severe PAH in patients with SARDs, and these findings provide evidence for PAH risk stratification in patients with SARDs.
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Affiliation(s)
- Hsin-Hua Chen
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.,Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Institute of Biomedical Science and Rong Hsing Research Centre for Translational Medicine, Chung Hsing University, Taichung, Taiwan.,Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan.,Department of Healthcare Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan.,Department of Public Health, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Tsu-Yi Hsieh
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Medical Education, Taichung Veterans General Hospital, Taichung, Taiwan.,Ph.D. Programme of Business, Feng Chia University, Taichung, Taiwan
| | - Der-Yuan Chen
- School of Medicine, China Medical University, Taichung, Taiwan.,Rheumatology and Immunology Centre, China Medical University Hospital, Taichung, Taiwan.,Translational Medicine Laboratory, Rheumatic Diseases Research Centre, China Medical University Hospital, Taichung, Taiwan
| | - Jia-Ching Ying
- Department of Management Information Systems, National Chung Hsing University, Taichung, Taiwan
| | - Wen-Cheng Chao
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Computer Science, Tunghai University, Taichung, Taiwan
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45
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Genuardi MV, Shpilsky D, Handen A, VanSpeybroeck G, Canterbury A, Lu M, Shapero K, Nieves RA, Thoma F, Mulukutla SR, Cavalcante JL, Chan SY. Increased Mortality in Patients With Preoperative and Persistent Postoperative Pulmonary Hypertension Undergoing Mitral Valve Surgery for Mitral Regurgitation: A Cohort Study. J Am Heart Assoc 2021; 10:e018394. [PMID: 33599144 PMCID: PMC8174242 DOI: 10.1161/jaha.120.018394] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Preoperative pulmonary hypertension (PH) is associated with excess mortality among patients with severe mitral regurgitation undergoing mitral valve surgery (MVS). However, the links between PH phenotype, pulmonary vascular remodeling, and persistent postoperative PH are not well understood. We aimed to describe the associations between components of pulmonary hemodynamics as well as postoperative residual PH with longitudinal mortality in patients with severe mitral regurgitation who received MVS. Methods and Results Patients undergoing MVS for severe mitral regurgitation from 2011 to 2016 were retrospectively identified within our health system (n=488). Mean pulmonary artery pressure and other hemodynamic variables were determined by presurgical right-heart catheterization. Postoperative pulmonary artery systolic pressure was assessed on echocardiogram 42 to 365 days post-MVS. Longitudinal survival over a mean 3.9 years of follow-up was evaluated using Cox proportional hazards modeling to compare survival after adjustment for demographics, surgical characteristics, and comorbidities. Pre-MVS prevalence of PH was high at 85%. After adjustment, each 10-mm Hg increase in preoperative mean pulmonary artery pressure was associated with a 1.38-fold increase in risk of death (95% CI, 1.13-1.68). Elevated preoperative pulmonary vascular resistance, transpulmonary gradient, and right atrial pressure were similarly associated with increased mortality. Among 231 patients with postoperative echocardiogram, evidence of PH on echocardiogram (pulmonary artery systolic pressure ≥35 mm Hg) was associated with increased risk of death (hazard ratio [HR], 2.02 [95% CI, 1.17-3.47]); however, this was no longer statistically significant after adjustment (HR, 1.55 [95% CI, 0.85-2.85]). Conclusions In patients undergoing MVS for mitral regurgitation, preoperative PH, and postoperative PH were associated with increased mortality.
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Affiliation(s)
- Michael V Genuardi
- Center for Pulmonary Vascular Biology and Medicine Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute Pittsburgh PA.,Division of Cardiology Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Daniel Shpilsky
- Division of Cardiology University of Pittsburgh School of Medicine Pittsburgh PA
| | - Adam Handen
- Center for Pulmonary Vascular Biology and Medicine Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute Pittsburgh PA
| | | | - Ann Canterbury
- Division of Cardiology University of Pittsburgh School of Medicine Pittsburgh PA
| | - Michael Lu
- Department of Medicine University of Pittsburgh School of Medicine Pittsburgh PA
| | - Kayle Shapero
- Division of Cardiology University of Pittsburgh School of Medicine Pittsburgh PA
| | - Ricardo A Nieves
- Division of Cardiology University of Pittsburgh School of Medicine Pittsburgh PA
| | - Floyd Thoma
- Division of Cardiology University of Pittsburgh School of Medicine Pittsburgh PA
| | - Suresh R Mulukutla
- Division of Cardiology University of Pittsburgh School of Medicine Pittsburgh PA
| | - João L Cavalcante
- Cardiovascular Imaging Center Minneapolis Heart InstituteAbbott Northwestern Hospital Minneapolis MN
| | - Stephen Y Chan
- Center for Pulmonary Vascular Biology and Medicine Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute Pittsburgh PA.,Division of Cardiology University of Pittsburgh School of Medicine Pittsburgh PA
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Žvirblytė R, Montvilaitė A, Tamulėnaitė E, Saniukaitė A, Ereminienė E, Vaškelytė JJ. Echocardiographic predictors of exercise induced pulmonary hypertension in patients with asymptomatic moderate to severe mitral regurgitation and preserved left ventricular ejection fraction. Perfusion 2021; 37:188-197. [PMID: 33509060 DOI: 10.1177/0267659120987545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The significant role of mitral regurgitation (MR) in development of pulmonary hypertension (PH) has been proved in previous studies. Experts suggest systolic pulmonary arterial pressure (SPAP) ⩾60 mmHg during exercise as a significant threshold of negative prognostic value in patients with MR. PURPOSE The aim of this study was to evaluate the changes of SPAP and to ascertain the determinants of exercise induced pulmonary hypertension (EIPH) in patients with asymptomatic primary MR. METHODS We performed a prospective study that included 50 patients with asymptomatic primary moderate to severe MR with preserved left ventricular ejection fraction (LV EF ⩾60%) at rest. They were divided into two groups according to the presence (PH group; n = 13) or absence (non-PH group; n = 37) of EIPH. Rest and stress (bicycle ergometry) echocardiography and speckle-tracking offline analysis were performed. RESULTS An increment of SPAP from rest to peak stress was higher in PH group (p < 0.001). Multivariate regression analysis showed that MR effective regurgitation orifice area (EROA; p = 0.008) and regurgitant volume (RVol; p = 0.006) contributed significantly to SPAP at rest. Higher increment of MR EROA during stress and worse parameters of LV diastolic function at rest (E, A, E/e') correlated significantly with higher SPAP during peak stress and they had a major role in predicting EIPH according to univariate logistic regression analysis. In ROC analysis SPAP >33.1 mmHg at rest could predict EIPH with 84.6% sensitivity and 87.1% specificity (95%CI 0.849-1.000; p < 0.001). CONCLUSIONS Parameters of MR severity (EROA and RVol) were significant determinants of SPAP at rest, while the increment of MR EROA during stress and parameters of resting LV diastolic function were the best predictors of significant EIPH.
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Affiliation(s)
- Rūta Žvirblytė
- Department of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Aistė Montvilaitė
- Department of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Eglė Tamulėnaitė
- Department of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Agnė Saniukaitė
- Department of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Eglė Ereminienė
- Department of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jolanta Justina Vaškelytė
- Department of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania.,The Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
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47
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Bermejo J, González-Mansilla A, Mombiela T, Fernández AI, Martínez-Legazpi P, Yotti R, García-Orta R, Sánchez-Fernández PL, Castaño M, Segovia-Cubero J, Escribano-Subias P, Alberto San Román J, Borrás X, Alonso-Gómez A, Botas J, Crespo-Leiro MG, Velasco S, Bayés-Genís A, López A, Muñoz-Aguilera R, Jiménez-Navarro M, González-Juanatey JR, Evangelista A, Elízaga J, Martín-Moreiras J, González-Santos JM, Moreno-Escobar E, Fernández-Avilés F. Persistent Pulmonary Hypertension in Corrected Valvular Heart Disease: Hemodynamic Insights and Long-Term Survival. J Am Heart Assoc 2021; 10:e019949. [PMID: 33399006 PMCID: PMC7955299 DOI: 10.1161/jaha.120.019949] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background The determinants and consequences of pulmonary hypertension after successfully corrected valvular heart disease remain poorly understood. We aim to clarify the hemodynamic bases and risk factors for mortality in patients with this condition. Methods and Results We analyzed long-term follow-up data of 222 patients with pulmonary hypertension and valvular heart disease successfully corrected at least 1 year before enrollment who had undergone comprehensive hemodynamic and imaging characterization as per the SIOVAC (Sildenafil for Improving Outcomes After Valvular Correction) clinical trial. Median (interquartile range) mean pulmonary pressure was 37 mm Hg (32-44 mm Hg) and pulmonary artery wedge pressure was 23 mm Hg (18-26 mm Hg). Most patients were classified either as having combined precapillary and postcapillary or isolated postcapillary pulmonary hypertension. After a median follow-up of 4.5 years, 91 deaths accounted for 4.21 higher-than-expected mortality in the age-matched population. Risk factors for mortality were male sex, older age, diabetes mellitus, World Health Organization functional class III and higher pulmonary vascular resistance-either measured by catheterization or approximated from ultrasound data. Higher pulmonary vascular resistance was related to diabetes mellitus and smaller residual aortic and mitral valve areas. In turn, the latter correlated with prosthetic nominal size. Six-month changes in the composite clinical score and in the 6-minute walk test distance were related to survival. Conclusions Persistent valvular heart disease-pulmonary hypertension is an ominous disease that is almost universally associated with elevated pulmonary artery wedge pressure. Pulmonary vascular resistance is a major determinant of mortality in this condition and is related to diabetes mellitus and the residual effective area of the corrected valve. These findings have important implications for individualizing valve correction procedures. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00862043.
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Affiliation(s)
- Javier Bermejo
- Hospital General Universitario Gregorio MarañónInstituto de Investigación Sanitaria Gregorio MarañónFacultad de Medicina, Universidad Complutense de Madrid, and CIBERCV Madrid Spain
| | - Ana González-Mansilla
- Hospital General Universitario Gregorio MarañónInstituto de Investigación Sanitaria Gregorio MarañónFacultad de Medicina, Universidad Complutense de Madrid, and CIBERCV Madrid Spain
| | - Teresa Mombiela
- Hospital General Universitario Gregorio MarañónInstituto de Investigación Sanitaria Gregorio MarañónFacultad de Medicina, Universidad Complutense de Madrid, and CIBERCV Madrid Spain
| | - Ana I Fernández
- Hospital General Universitario Gregorio MarañónInstituto de Investigación Sanitaria Gregorio MarañónFacultad de Medicina, Universidad Complutense de Madrid, and CIBERCV Madrid Spain
| | - Pablo Martínez-Legazpi
- Hospital General Universitario Gregorio MarañónInstituto de Investigación Sanitaria Gregorio MarañónFacultad de Medicina, Universidad Complutense de Madrid, and CIBERCV Madrid Spain
| | | | | | | | | | | | | | | | - Xavier Borrás
- Hospital Santa Creu i San Pau and CIBERCV Barcelona Spain
| | | | - Javier Botas
- Hospital Universitario Fundación Alcorcón Alcorcón Spain
| | | | | | | | - Amador López
- Hospital Universitario Reina Sofía Córdoba Spain
| | | | | | | | | | - Jaime Elízaga
- Hospital General Universitario Gregorio MarañónInstituto de Investigación Sanitaria Gregorio MarañónFacultad de Medicina, Universidad Complutense de Madrid, and CIBERCV Madrid Spain
| | | | | | | | - Francisco Fernández-Avilés
- Hospital General Universitario Gregorio MarañónInstituto de Investigación Sanitaria Gregorio MarañónFacultad de Medicina, Universidad Complutense de Madrid, and CIBERCV Madrid Spain
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48
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Ghaffar FA, Redzuan AM, Makmor-Bakry M. Effectiveness of Sildenafil in Pulmonary Hypertension Secondary to Valvular Heart Disease: A Systematic Review and Meta-Analysis. ARCHIVES OF PHARMACY PRACTICE 2021. [DOI: 10.51847/tcievrcfgf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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49
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Santiago‐Vacas E, Lupón J, Gavidia‐Bovadilla G, Gual‐Capllonch F, Antonio M, Domingo M, Núñez J, Zamora E, Teis A, Moliner P, Codina P, Santesmases J, Bayes‐Genis A. Pulmonary hypertension and right ventricular dysfunction in heart failure: prognosis and 15‐year prospective longitudinal trajectories in survivors. Eur J Heart Fail 2020; 22:1214-1225. [DOI: 10.1002/ejhf.1862] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 11/08/2022] Open
Affiliation(s)
- Evelyn Santiago‐Vacas
- Heart Failure Unit, Hospital Universitari Germans Trias i Pujol Badalona Spain
- Cardiology Department Hospital Universitari Germans Trias i Pujol Badalona Spain
- Department of Medicine Universitat de Barcelona Barcelona Spain
| | - Josep Lupón
- Heart Failure Unit, Hospital Universitari Germans Trias i Pujol Badalona Spain
- Cardiology Department Hospital Universitari Germans Trias i Pujol Badalona Spain
- Department of Medicine Universitat Autònoma de Barcelona Barcelona Spain
- CIBER Cardiovascular, Instituto de Salud Carlos III Madrid Spain
| | | | | | - Marta Antonio
- Heart Failure Unit, Hospital Universitari Germans Trias i Pujol Badalona Spain
- Cardiology Department Hospital Universitari Germans Trias i Pujol Badalona Spain
| | - Mar Domingo
- Heart Failure Unit, Hospital Universitari Germans Trias i Pujol Badalona Spain
| | - Julio Núñez
- CIBER Cardiovascular, Instituto de Salud Carlos III Madrid Spain
- Cardiology Department Hospital Clínico Universitario, INCLIVA València Spain
- Department of Medicine Universitat de València València Spain
| | - Elisabet Zamora
- Heart Failure Unit, Hospital Universitari Germans Trias i Pujol Badalona Spain
- Cardiology Department Hospital Universitari Germans Trias i Pujol Badalona Spain
- Department of Medicine Universitat Autònoma de Barcelona Barcelona Spain
- CIBER Cardiovascular, Instituto de Salud Carlos III Madrid Spain
| | - Albert Teis
- Cardiology Department Hospital Universitari Germans Trias i Pujol Badalona Spain
| | - Pedro Moliner
- Heart Failure Unit, Hospital Universitari Germans Trias i Pujol Badalona Spain
- Cardiology Department Hospital Universitari Germans Trias i Pujol Badalona Spain
| | - Pau Codina
- Heart Failure Unit, Hospital Universitari Germans Trias i Pujol Badalona Spain
- Cardiology Department Hospital Universitari Germans Trias i Pujol Badalona Spain
| | - Javier Santesmases
- Heart Failure Unit, Hospital Universitari Germans Trias i Pujol Badalona Spain
| | - Antoni Bayes‐Genis
- Heart Failure Unit, Hospital Universitari Germans Trias i Pujol Badalona Spain
- Cardiology Department Hospital Universitari Germans Trias i Pujol Badalona Spain
- Department of Medicine Universitat Autònoma de Barcelona Barcelona Spain
- CIBER Cardiovascular, Instituto de Salud Carlos III Madrid Spain
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50
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Koslow M, Epstein Shochet G, Fenadka F, Neuman Y, Osadchy A, Shitrit D. Systemic Thrombolysis Therapy is Associated With Improved Outcomes Among Patients With Acute Pulmonary Embolism and Respiratory Failure. Am J Med Sci 2020; 360:129-136. [PMID: 32466857 DOI: 10.1016/j.amjms.2020.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 03/15/2020] [Accepted: 04/23/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Thrombolytic therapy is widely accepted for massive pulmonary embolism (PE) due to the high mortality risk associated with standard anticoagulation alone. Its role in submassive PE, however, has remained controversial. We aimed to evaluate whether the selective use of systemic thrombolytic therapy with intravenous tissue plasminogen activator (IV-tPA) improves the survival of patients with submassive PE at increased risk for clinical deterioration. METHODS A total of 184 consecutive patients diagnosed with acute PE by chest thoracic angiography (CTA) were included in a retrospective study. Pulmonary artery obstruction and right/left ventricular dysfunction were evaluated by CTA and echocardiography. Medical history and simplified PE Severity Index (sPESI) were assessed at diagnosis. Hemodynamic and respiratory status were recorded at diagnosis, admission to pulmonary unit and prior to thrombolytic therapy. Patient survival was assessed at 30 of 90 days from diagnosis by CTA. RESULTS All low risk patients (36%) per sPESI survived. Among the 117 remaining patients, 31% received IV-tPA. Respiratory failure was associated with decreased age-adjusted survival (P = 0.005). Among patients with respiratory failure selected for IV-tPA, age-adjusted survival was improved significantly compared to others (P = 0.043). CONCLUSIONS Thrombolytic therapy for hemodynamically stable PE patients with respiratory failure may improve survival. TRIAL REGISTRATION MMC-0216-14.
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Affiliation(s)
- Matthew Koslow
- Division of Pulmonary, Critical Care and Sleep Medicine, Interstitial Lung Disease Program, National Jewish Health, Denver, Colorado; Pulmonary Department, Meir Medical Center, Kfar Saba, Israel
| | - Gali Epstein Shochet
- Pulmonary Department, Meir Medical Center, Kfar Saba, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Feda Fenadka
- Department of Radiology, Meir Medical Center, Kfar Saba, Israel
| | - Yoram Neuman
- Department of Cardiology, Meir Medical Center, Kfar Saba, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - David Shitrit
- Pulmonary Department, Meir Medical Center, Kfar Saba, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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