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Naguib M, Aljwaid A, Marella D, Flores RJ, Singh A. Nitroprusside Combined with Leg Raise at the Time of Right Heart Catheterization to Differentiate Precapillary from Other Hemodynamic Forms of Pulmonary Hypertension: A Single-Center Pilot Study. J Cardiovasc Dev Dis 2024; 11:124. [PMID: 38667742 PMCID: PMC11050046 DOI: 10.3390/jcdd11040124] [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: 01/23/2024] [Revised: 04/13/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
Pulmonary hypertension (PH) can arise from several distinct disease processes, with a percentage presenting with combined pre- and postcapillary pulmonary hypertension (cpcPH). Patients with cpcPH are unsuitable candidates for PH-directed therapies due to elevated pulmonary capillary wedge pressures (PCWPs); however, the PCWP is dynamic and is affected by both preload and afterload. Many patients that are diagnosed with cpcPH are hypertensive at the time of right heart catheterization which has the potential to increase the PCWP and, therefore, mimic a more postcapillary-predominant phenotype. In this small pilot study, we examine the effect of nitroprusside combined with dynamic preload augmentation with a passive leg raise maneuver in hypertensive cpcPH patients at the time of right heart catheterization to identify a more precapillary-dominant PH phenotype. Patients that met the criteria of PCWP ≤ 15 mmHg with nitroprusside infusion and PCWP ≤ 18 mmHg with nitroprusside infusion and simultaneous leg raise were started on pulmonary vascular-targeted therapy. Long-term PH therapy was well tolerated, with increased six-minute walk distance, improved WHO functional class, decreased NT-proBNP, and improved REVEAL 2.0 Lite Risk Score in this precapillary-dominant PH phenotype. This small study highlights the importance of characterizing patient physiology beyond resting conditions at the time of right heart catheterization.
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Affiliation(s)
- Mostafa Naguib
- Department of Internal Medicine, Morristown Medical Center, Morristown, NJ 07960, USA
| | - Ahmed Aljwaid
- Department of Internal Medicine, Morristown Medical Center, Morristown, NJ 07960, USA
| | - Dean Marella
- Department of Cardiology, Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ 07960, USA
| | - Raul J. Flores
- Heart Success Program (Advanced Heart Failure Program), Department of Cardiology, Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ 07960, USA
| | - Abhishek Singh
- Heart Success Program (Advanced Heart Failure Program), Department of Cardiology, Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ 07960, USA
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Yim IHW, Parker KH, Drury NE, Lim HS. Pulmonary artery wave intensity analysis in pulmonary hypertension associated with heart failure and reduced left ventricular ejection fraction. Pulm Circ 2024; 14:e12345. [PMID: 38348196 PMCID: PMC10859878 DOI: 10.1002/pul2.12345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/27/2023] [Accepted: 01/26/2024] [Indexed: 02/15/2024] Open
Abstract
Wave intensity analysis (WIA) uses simultaneous changes in pressure and flow velocity to determine wave energy, type, and timing of traveling waves in the circulation. In this study, we characterized wave propagation in the pulmonary artery in patients with pulmonary hypertension associated with left-sided heart disease (PHLHD) and the effects of dobutamine. During right heart catheterization, pressure and velocity data were acquired using a dual-tipped pressure and Doppler flow sensor wire (Combowire; Phillips Volcano), and processed offline using customized Matlab software (MathWorks). Patients with low cardiac output underwent dobutamine challenge. Twenty patients with PHLHD (all heart failure with reduced left ventricular ejection fraction) were studied. Right ventricular systole produced a forward compression wave (FCW), followed by a forward decompression wave (FDW) during diastole. Wave reflection manifesting as backward compression wave (BCW) following the FCW was observed in 14 patients. Compared to patients without BCW, patients with BCW had higher mean pulmonary artery pressure (28.7 ± 6.12 vs. 38.6 ± 6.5 mmHg, p = 0.005), and lower pulmonary arterial capacitance (PAC: 2.88 ± 1.75 vs. 1.73 ± 1.16, p = 0.002). Pulmonary vascular resistance was comparable. Mean pulmonary artery pressure of 34.5 mmHg (area under the curve [AUC]: 0.881) and PAC of 2.29 mL/mmHg (AUC: 0.833) predicted BCW. The magnitude of the FCW increased with dobutamine (n = 11) and correlated with pulmonary artery wedge pressure. Wave reflection in PHLHD is more likely at higher pulmonary artery pressures and lower PAC and the magnitude of reflected waves correlated with pulmonary artery wedge pressure. Dobutamine increased FCW but did not affect wave reflection.
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Affiliation(s)
- Ivan H. W. Yim
- Department of Cardiac SurgeryUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
- Institute of Cardiovascular SciencesUniversity of BirminghamBirminghamUK
| | - Kim H. Parker
- Department of Biomedical EngineeringImperial CollegeLondonUK
| | - Nigel E. Drury
- Department of Cardiac SurgeryUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
- Institute of Cardiovascular SciencesUniversity of BirminghamBirminghamUK
| | - Hoong Sern Lim
- Department of Cardiac SurgeryUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
- Institute of Cardiovascular SciencesUniversity of BirminghamBirminghamUK
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Abstract
Patients with heart failure (HF) often have pulmonary hypertension (PH), which is mainly post-capillary; however, some of them also develop a pre-capillary component. The exact mechanisms leading to combined pre- and post-capillary PH are not yet clear, but the phenomenon seems to start from a passive transmission of increased pressure from the left heart to the lungs, and then continues with the remodeling of both the alveolar and vascular components through different pathways. More importantly, it is not yet clear which patients are predisposed to develop the disease. These patients have some characteristics similar to those with idiopathic pulmonary arterial hypertension (e.g., young age and frequent incidence in female gender), but they share cardiovascular risk factors with patients with HF (e.g., obesity and diabetes), with both reduced and preserved ejection fraction. Thanks to echocardiography parameters and newly introduced scores, more tools are available to distinguish between idiopathic pulmonary arterial hypertension and combined PH and to guide patients' management. It may be hypothesized to treat patients in whom the pre-capillary component is predominant with specific therapies such as those for idiopathic pulmonary arterial hypertension; however, no adequately powered trials of PH-specific treatment are available in combined PH. Early evidence of clinical benefit has been proven in some trials on phosphodiesterase type 5 inhibitors, while data on prostacyclin analogues, endothelin-1 receptor antagonists, and soluble guanylate cyclase stimulators are still controversial.
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Boxhammer E, Mirna M, Bäz L, Alushi B, Franz M, Kretzschmar D, Hoppe UC, Lauten A, Lichtenauer M. Comparison of PCWP and LVEDP Measurements in Patients with Severe Aortic Stenosis Undergoing TAVI-Same Same but Different? J Clin Med 2022; 11:jcm11112978. [PMID: 35683367 PMCID: PMC9181042 DOI: 10.3390/jcm11112978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/18/2022] [Accepted: 05/23/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pulmonary capillary wedge pressure (PCWP) and left ventricular end-diastolic pressure (LVEDP) are often used as equivalents for determination of pulmonary hypertension (PH). PH is a comorbidity in patients with severe aortic valve stenosis (AS) and associated with limited prognosis. The aim of the study was to examine the role of differentiated classification basis of PCWP and LVEDP in patients planning for transcatheter aortic valve implantation (TAVI). METHODS 284 patients with severe AS completed a combined left (LHC) and right heart catheterization (RHC) as part of a TAVI planning procedure. Patients were categorized twice into subtypes of PH according to 2015 European Society of Cardiology (ESC) guidelines-on the one hand with PCWP and on the other hand with LVEDP as classification basis. PCWP-LVEDP relationships were figured out using Kaplan-Meier curves, linear regressions and Bland-Altman analysis. RESULTS Regarding 1-year mortality, Kaplan-Meier analyses showed similar curves in spite of different classification bases of PH subtypes according to PCWP or LVEDP with exception of pre-capillary PH subtype. PCWP-LVEDP association in the overall cohort was barely present (R = 0.210, R2 = 0.044). When focusing analysis on PH patients only a slightly increased linear regression was noted compared to the overall cohort (R = 0.220, R2 = 0.048). The strongest regression was observed in patients with creatinine ≥ 132 µmol/L (R = 0.357, R2 = 0.127) and in patients with mitral regurgitation ≥ II° (R = 0.326, R2 = 0.106). CONCLUSIONS In patients with severe AS, there is a weak association between hemodynamic parameters measured by LHC and RHC. RHC measurements alone are not suitable for risk stratification with respect to one-year mortality. If analysis of hemodynamic parameters is necessary in patients with severe AS scheduled for TAVI, measurement results of LHC and RHC should be combined and LVEDP could serve as a helpful indicator for risk assessment.
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Affiliation(s)
- Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (M.M.); (U.C.H.)
| | - Moritz Mirna
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (M.M.); (U.C.H.)
| | - Laura Bäz
- Universitäts-Herzzentrum Thüringen, Clinic of Internal Medicine I, Department of Cardiology, Friedrich Schiller University, 07743 Jena, Germany; (L.B.); (M.F.); (D.K.)
| | - Brunilda Alushi
- Department of General and Interventional Cardiology and Rhythmology, Helios Hospital Erfurt, 99089 Erfurt, Germany; (B.A.); (A.L.)
| | - Marcus Franz
- Universitäts-Herzzentrum Thüringen, Clinic of Internal Medicine I, Department of Cardiology, Friedrich Schiller University, 07743 Jena, Germany; (L.B.); (M.F.); (D.K.)
| | - Daniel Kretzschmar
- Universitäts-Herzzentrum Thüringen, Clinic of Internal Medicine I, Department of Cardiology, Friedrich Schiller University, 07743 Jena, Germany; (L.B.); (M.F.); (D.K.)
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (M.M.); (U.C.H.)
| | - Alexander Lauten
- Department of General and Interventional Cardiology and Rhythmology, Helios Hospital Erfurt, 99089 Erfurt, Germany; (B.A.); (A.L.)
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Berlin, 10785 Berlin, Germany
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (M.M.); (U.C.H.)
- Correspondence:
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Resolution of Precapillary Pulmonary Hypertension After Liver Transplantation for Hereditary Hemorrhagic Telangiectasia: Systematic Review and Case Report. Transplant Proc 2022; 54:135-143. [PMID: 34974893 DOI: 10.1016/j.transproceed.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/17/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND Pulmonary hypertension (PH) is a known complication of hereditary hemorrhagic telangiectasia (HHT) in patients with hepatic arteriovenous malformations (HAVM). Orthotopic liver transplantation (OLT) is a recognized treatment of HAVM in HHT, but its effect on PH has not been reported in detail before. METHODS Systematic review on HHT patients with pre- or postcapillary PH who underwent OLT and report of a case. RESULTS Twenty-one patients were included from 7 articles, all case reports or case series. All had high-output cardiac failure prior to OLT. Two patients had precapillary PH, both related to ALK1 mutations. All patients but 1 showed significant improvement or complete resolution of PH after transplantation. One patient died of acute cardiac failure postoperatively. We also report the case of a 72-year-old woman with type 3 HHT and severe mixed pre- and postcapillary PH. The patient presented with multiple HAVM, left-to-right shunting, and severe but partially reversible combined pre- and postcapillary PH, without ALK1 mutation. After recurrent cholangitis episodes, liver abscesses, and severe obstruction of the right-sided biliary tree, an interdisciplinary decision was taken to proceed with OLT despite PH. Intraoperatively, PH resolved almost instantly after hepatic artery ligation and hepatectomy. CONCLUSIONS In our patient, OLT completely abrogated mixed pre- and postcapillary PH. Based on this systematic review, we suggest that OLT should be considered a viable treatment option in patients with HHT, HAVM, and mixed pre- and postcapillary PH, featuring cardiac failure and drug responsive PH, rather than being seen as a major risk factor for cardiopulmonary complications.
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Lei Q, Yu Z, Li H, Cheng J, Wang Y. Fatty acid-binding protein 5 aggravates pulmonary artery fibrosis in pulmonary hypertension secondary to left heart disease via activating wnt/β-catenin pathway. J Adv Res 2021; 40:197-206. [PMID: 36100327 PMCID: PMC9481948 DOI: 10.1016/j.jare.2021.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 10/01/2021] [Accepted: 11/21/2021] [Indexed: 02/08/2023] Open
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Nawaytou H, Fineman JR, Moledina S, Ivy D, Abman SH, Cerro MJD. Practice patterns of pulmonary hypertension secondary to left heart disease among pediatric pulmonary hypertension providers. Pulm Circ 2021; 11:2045894021991446. [PMID: 33623667 PMCID: PMC7879002 DOI: 10.1177/2045894021991446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/07/2021] [Indexed: 11/16/2022] Open
Abstract
Development of pulmonary hypertension (PH) in patients with left side heart disease (LHD) is a predictor of poor prognosis. The use of pulmonary vasodilators in PH associated with LHD (PH-LHD) is controversial. In this study, we describe the practice patterns regarding the use of pulmonary vasodilators in PH-LHD among a group of international pediatric PH specialists. A survey was distributed to the members of three pediatric PH networks: PPHNet, PVRI, and REHIPED. The survey queried participants on the rationale, indications, and contraindications of the use of pulmonary vasodilators in children with PH-LHD. Forty-seven PH specialists from 39 PH centers completed the survey. Participants included PH specialists from North America (57%), South America (15%), and Europe (19%). The majority of participants (74%) recommended the use of pulmonary vasodilators only in patients with combined pre-capillary and post-capillary pulmonary hypertension. Participants required the presence of clinical symptoms or signs of heart failure (68%) or right ventricular dysfunction by echocardiography (51%) in order to recommend pulmonary vasodilator therapy. There was no agreement regarding hemodynamic criteria used to recommend pulmonary vasodilators or the etiologies of LHD considered contraindications for using pulmonary vasodilators to manage PH-LHD. Of the available PH-targeted drugs, most participants preferred the use of phosphodiesterase-5-inhibitors for this indication. In conclusion, the practice of recommending pulmonary vasodilators in PH-LHD is highly variable among international pediatric PH specialists. Most specialists of those surveyed (57% in North America) would consider the use of pulmonary vasodilators in PH-LHD only if pre-capillary pulmonary hypertension and right ventricular dysfunction are present.
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Affiliation(s)
- Hythem Nawaytou
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Jeffrey R Fineman
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Shahin Moledina
- Department of Pediatrics, University College London, London, UK
| | - Dunbar Ivy
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven H Abman
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Maria J Del Cerro
- Department of Pediatric Cardiology, Ramon y Cajal University Hospital, Madrid, Spain
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Cai Z, van Duin RWB, Stam K, Uitterdijk A, van der Velden J, Vonk Noordegraaf A, Duncker DJ, Merkus D. Right ventricular oxygen delivery as a determinant of right ventricular functional reserve during exercise in juvenile swine with chronic pulmonary hypertension. Am J Physiol Heart Circ Physiol 2019; 317:H840-H850. [PMID: 31398061 DOI: 10.1152/ajpheart.00130.2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Assessing right ventricular (RV) functional reserve is important for determining clinical status and prognosis in patients with pulmonary hypertension (PH). In this study, we aimed to establish RV oxygen (O2) delivery as a determinant for RV functional reserve during exercise in swine with chronic PH. Chronic PH was induced by pulmonary vein banding (PVB), with sham operation serving as control. RV function and RV O2 delivery were measured over time in chronically instrumented swine, up to 12 wk after PVB at rest and during exercise. At rest, RV afterload (pulmonary artery pressure and arterial elastance) and contractility (Ees and dP/dtmax) were higher in PH compared with control with preserved cardiac index and RV O2 delivery. However, RV functional reserve, as measured by the exercise-induced relative change (Δ) in cardiac index, dP/dtmax, and end-systolic elastance (Ees), was decreased in PH, and RV pulmonary arterial coupling was lower both at rest and during exercise in PH. Furthermore, the increase in RV O2 delivery was attenuated in PH during exercise principally due to a lower systolic coronary blood flow in combination with an attenuated increase in aorta pressure while arterial O2 content was not significantly altered in PH. Moreover, RV O2 delivery reserve correlated with RV functional reserve, Δcardiac index (r2 = 0.85), ΔdP/dtmax (r2 = 0.49), and ΔEes (r2 = 0.70), all P < 0.05. The inability to sufficiently increase RV O2 supply to meet the increased O2 demand during exercise is principally due to the reduced RV perfusion relative to healthy control values and likely contributes to impaired RV contractile function and thereby to the limited exercise capacity that is commonly observed in patients with PH.NEW & NOTEWORTHY Impaired right ventricular (RV) O2 delivery reserve is associated with reduced RV functional reserve during exercise in a swine model of pulmonary hypertension (PH) induced by pulmonary vein banding. Our data suggest that RV function and exercise capacity might be improved by improving RV O2 delivery.
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Affiliation(s)
- Zongye Cai
- Experimental Cardiology, Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Richard W B van Duin
- Experimental Cardiology, Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Kelly Stam
- Experimental Cardiology, Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - André Uitterdijk
- Experimental Cardiology, Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jolanda van der Velden
- Department of Physiology, Amsterdam University Medical Center, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam University Medical Center, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Dirk J Duncker
- Experimental Cardiology, Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Daphne Merkus
- Experimental Cardiology, Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
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Ranchoux B, Nadeau V, Bourgeois A, Provencher S, Tremblay É, Omura J, Coté N, Abu-Alhayja'a R, Dumais V, Nachbar RT, Tastet L, Dahou A, Breuils-Bonnet S, Marette A, Pibarot P, Dupuis J, Paulin R, Boucherat O, Archer SL, Bonnet S, Potus F. Metabolic Syndrome Exacerbates Pulmonary Hypertension due to Left Heart Disease. Circ Res 2019; 125:449-466. [PMID: 31154939 DOI: 10.1161/circresaha.118.314555] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
RATIONALE Pulmonary hypertension (PH) due to left heart disease (LHD), or group 2 PH, is the most prevalent form of PH worldwide. PH due to LHD is often associated with metabolic syndrome (MetS). In 12% to 13% of cases, patients with PH due to LHD display vascular remodeling of pulmonary arteries (PAs) associated with poor prognosis. Unfortunately, the underlying mechanisms remain unknown; PH-targeted therapies for this group are nonexistent, and the development of a new preclinical model is crucial. Among the numerous pathways dysregulated in MetS, inflammation plays also a critical role in both PH and vascular remodeling. OBJECTIVE We hypothesized that MetS and inflammation may trigger the development of vascular remodeling in group 2 PH. METHODS AND RESULTS Using supracoronary aortic banding, we induced diastolic dysfunction in rats. Then we induced MetS by a combination of high-fat diet and olanzapine treatment. We used metformin treatment and anti-IL-6 (interleukin-6) antibodies to inhibit the IL-6 pathway. Compared with sham conditions, only supracoronary aortic banding+MetS rats developed precapillary PH, as measured by both echocardiography and right/left heart catheterization. PH in supracoronary aortic banding+MetS was associated with macrophage accumulation and increased IL-6 production in lung. PH was also associated with STAT3 (signal transducer and activator of transcription 3) activation and increased proliferation of PA smooth muscle cells, which contributes to remodeling of distal PA. We reported macrophage accumulation, increased IL-6 levels, and STAT3 activation in the lung of group 2 PH patients. In vitro, IL-6 activates STAT3 and induces human PA smooth muscle cell proliferation. Metformin treatment decreased inflammation, IL-6 levels, STAT3 activation, and human PA smooth muscle cell proliferation. In vivo, in the supracoronary aortic banding+MetS animals, reducing IL-6, either by anti-IL-6 antibody or metformin treatment, reversed pulmonary vascular remodeling and improve PH due to LHD. CONCLUSIONS We developed a new preclinical model of group 2 PH by combining MetS with LHD. We showed that MetS exacerbates group 2 PH. We provided evidence for the importance of the IL-6-STAT3 pathway in our experimental model of group 2 PH and human patients.
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Affiliation(s)
- Benoît Ranchoux
- From the Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Canada (B.R., V.N., A.B., S.P., E.T., J.O., N.C., R.A-A., L.T., A.D., S.B.-B., P.P., R.P., O.B., S.B., F.P.)
| | - Valérie Nadeau
- From the Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Canada (B.R., V.N., A.B., S.P., E.T., J.O., N.C., R.A-A., L.T., A.D., S.B.-B., P.P., R.P., O.B., S.B., F.P.)
| | - Alice Bourgeois
- From the Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Canada (B.R., V.N., A.B., S.P., E.T., J.O., N.C., R.A-A., L.T., A.D., S.B.-B., P.P., R.P., O.B., S.B., F.P.)
| | - Steeve Provencher
- From the Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Canada (B.R., V.N., A.B., S.P., E.T., J.O., N.C., R.A-A., L.T., A.D., S.B.-B., P.P., R.P., O.B., S.B., F.P.)
| | - Éve Tremblay
- From the Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Canada (B.R., V.N., A.B., S.P., E.T., J.O., N.C., R.A-A., L.T., A.D., S.B.-B., P.P., R.P., O.B., S.B., F.P.)
| | - Junichi Omura
- From the Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Canada (B.R., V.N., A.B., S.P., E.T., J.O., N.C., R.A-A., L.T., A.D., S.B.-B., P.P., R.P., O.B., S.B., F.P.)
| | - Nancy Coté
- From the Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Canada (B.R., V.N., A.B., S.P., E.T., J.O., N.C., R.A-A., L.T., A.D., S.B.-B., P.P., R.P., O.B., S.B., F.P.)
| | - Rami Abu-Alhayja'a
- From the Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Canada (B.R., V.N., A.B., S.P., E.T., J.O., N.C., R.A-A., L.T., A.D., S.B.-B., P.P., R.P., O.B., S.B., F.P.)
| | - Valérie Dumais
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Québec City, Canada (V.D., R.T.N., A.M.)
| | - Renato T Nachbar
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Québec City, Canada (V.D., R.T.N., A.M.)
| | - Lionel Tastet
- From the Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Canada (B.R., V.N., A.B., S.P., E.T., J.O., N.C., R.A-A., L.T., A.D., S.B.-B., P.P., R.P., O.B., S.B., F.P.)
| | - Abdellaziz Dahou
- From the Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Canada (B.R., V.N., A.B., S.P., E.T., J.O., N.C., R.A-A., L.T., A.D., S.B.-B., P.P., R.P., O.B., S.B., F.P.)
| | - Sandra Breuils-Bonnet
- From the Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Canada (B.R., V.N., A.B., S.P., E.T., J.O., N.C., R.A-A., L.T., A.D., S.B.-B., P.P., R.P., O.B., S.B., F.P.)
| | - André Marette
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Québec City, Canada (V.D., R.T.N., A.M.)
| | - Philippe Pibarot
- From the Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Canada (B.R., V.N., A.B., S.P., E.T., J.O., N.C., R.A-A., L.T., A.D., S.B.-B., P.P., R.P., O.B., S.B., F.P.)
| | - Jocelyn Dupuis
- Institut de cardiologie de Montréal, Québec, Canada (J.D.)
| | - Roxane Paulin
- From the Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Canada (B.R., V.N., A.B., S.P., E.T., J.O., N.C., R.A-A., L.T., A.D., S.B.-B., P.P., R.P., O.B., S.B., F.P.)
| | - Olivier Boucherat
- From the Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Canada (B.R., V.N., A.B., S.P., E.T., J.O., N.C., R.A-A., L.T., A.D., S.B.-B., P.P., R.P., O.B., S.B., F.P.)
| | - Stephen L Archer
- Department of Medicine, Queen's University, Kingston, Ontario, Canada (S.L.A., F.P.)
| | - Sébastien Bonnet
- From the Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Canada (B.R., V.N., A.B., S.P., E.T., J.O., N.C., R.A-A., L.T., A.D., S.B.-B., P.P., R.P., O.B., S.B., F.P.)
| | - François Potus
- From the Pulmonary Hypertension Research Group of the Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Québec City, Canada (B.R., V.N., A.B., S.P., E.T., J.O., N.C., R.A-A., L.T., A.D., S.B.-B., P.P., R.P., O.B., S.B., F.P.).,Department of Medicine, Queen's University, Kingston, Ontario, Canada (S.L.A., F.P.)
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10
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Moghaddam N, Swiston JR, Levy RD, Lee L, Huckell VF, Brunner NW. Clinical and hemodynamic factors in predicting response to fluid challenge during right heart catheterization. Pulm Circ 2018; 9:2045894018819803. [PMID: 30507348 PMCID: PMC6300866 DOI: 10.1177/2045894018819803] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Fluid challenge during right heart catheterization has been used for unmasking pulmonary hypertension (PH) related to left-sided heart disease. We evaluated the clinical and hemodynamic factors affecting the response to fluid challenge and investigated the role of fluid challenge in the classification and management of PH patients. We reviewed the charts of 67 patients who underwent fluid challenge with a baseline pulmonary arterial wedge pressure (PAWP) of ≤ 18 mmHg. A positive fluid challenge (PFC) was defined as an increase in PAWP to > 18 mmHg after 500 mL saline infusion. Clinical characteristics and echocardiographic and hemodynamic parameters were compared between PFC and negative fluid challenge (NFC). PFC was associated with female sex, increased BMI, and hypertension. A greater rise in PAWP was observed in PFC (6.8 ± 2.3 vs. 3.8 ± 2.7 mmHg, P = 0.001). A larger increase in PAWP correlated with a lower transpulmonary gradient (r = –0.42, P < 0.001), diastolic pulmonary gradient (r = –0.42, P < 0.001), and pulmonary vascular resistance (r = –0.38, P < 0.001). We found 100% of the patients with PFC were classified as WHO group 2 PH compared to 49% of the NFC patients (P < 0.001). Fewer patients with PFC were started on advanced PH therapies and more were discharged from PH clinic. A PFC and the magnitude of PAWP increase after saline loading are associated with parameters related to left heart disease. In our population, fluid challenge appeared to influence the classification of PH and whether patients are started on therapy or discharged from clinic.
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Affiliation(s)
- Nima Moghaddam
- 1 Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - John R Swiston
- 2 Division of Respirolgy, University of British Columbia, Vancouver, BC, Canada
| | - Robert D Levy
- 2 Division of Respirolgy, University of British Columbia, Vancouver, BC, Canada
| | - Lisa Lee
- 2 Division of Respirolgy, University of British Columbia, Vancouver, BC, Canada
| | - Victor F Huckell
- 3 Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | - Nathan W Brunner
- 3 Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
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11
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van Duin RWB, Stam K, Cai Z, Uitterdijk A, Garcia-Alvarez A, Ibanez B, Danser AHJ, Reiss IKM, Duncker DJ, Merkus D. Transition from post-capillary pulmonary hypertension to combined pre- and post-capillary pulmonary hypertension in swine: a key role for endothelin. J Physiol 2018; 597:1157-1173. [PMID: 29799120 PMCID: PMC6375874 DOI: 10.1113/jp275987] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/11/2018] [Indexed: 12/31/2022] Open
Abstract
Key points Passive, isolated post‐capillary pulmonary hypertension (PH) secondary to left heart disease may progress to combined pre‐ and post‐capillary or ‘active’ PH This ‘activation’ of post‐capillary PH significantly increases morbidity and mortality, and is still incompletely understood. In this study, pulmonary vein banding gradually produced post‐capillary PH with structural and functional microvascular remodelling in swine. Ten weeks after banding, the pulmonary endothelin pathway was upregulated, likely contributing to pre‐capillary aspects in the initially isolated post‐capillary PH. Inhibition of the endothelin pathway could potentially stop the progression of early stage post‐capillary PH.
Abstract Passive, isolated post‐capillary pulmonary hypertension (IpcPH) secondary to left heart disease may progress to combined pre‐ and post‐capillary or ‘active’ PH (CpcPH) characterized by chronic pulmonary vascular constriction and remodelling. The mechanisms underlying this ‘activation’ of passive pulmonary hypertension (PH) remain incompletely understood. Here we investigated the role of the vasoconstrictor endothelin‐1 (ET) in the progression from IpcPH to CpcPH in a swine model for post‐capillary PH. Swine underwent pulmonary vein banding (PVB; n = 7) or sham‐surgery (Sham; n = 6) and were chronically instrumented 4 weeks later. Haemodynamics were assessed for 8 weeks, at rest and during exercise, before and after administration of the ET receptor antagonist tezosentan. After sacrifice, the pulmonary vasculature was investigated by histology, RT‐qPCR and myograph experiments. Pulmonary arterial pressure and resistance increased significantly over time. mRNA expression of prepro‐endothelin‐1 and endothelin converting enzyme‐1 in the lung was increased, while ETA expression was unchanged and ETB expression was downregulated. This was associated with increased plasma ET levels from week 10 onward and a more pronounced vasodilatation to in vivo administration of tezosentan at rest and during exercise. Myograph experiments showed decreased endothelium‐dependent vasodilatation to Substance P and increased vasoconstriction to KCl in PVB swine consistent with increased muscularization observed with histology. Moreover, maximal vasoconstriction to ET was increased whereas ET sensitivity was decreased. In conclusion, PVB swine gradually developed PH with structural and functional vascular remodelling. From week 10 onward, the pulmonary ET pathway was upregulated, likely contributing to pre‐capillary activation of the initially isolated post‐capillary PH. Inhibition of the ET pathway could thus potentially provide a pharmacotherapeutic target for early stage post‐capillary PH. Passive, isolated post‐capillary pulmonary hypertension (PH) secondary to left heart disease may progress to combined pre‐ and post‐capillary or ‘active’ PH This ‘activation’ of post‐capillary PH significantly increases morbidity and mortality, and is still incompletely understood. In this study, pulmonary vein banding gradually produced post‐capillary PH with structural and functional microvascular remodelling in swine. Ten weeks after banding, the pulmonary endothelin pathway was upregulated, likely contributing to pre‐capillary aspects in the initially isolated post‐capillary PH. Inhibition of the endothelin pathway could potentially stop the progression of early stage post‐capillary PH.
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Affiliation(s)
- Richard W B van Duin
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Kelly Stam
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Zongye Cai
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - André Uitterdijk
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Ana Garcia-Alvarez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,Hospital Clinic of Barcelona, IDIBAPS, Barcelona, Spain
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,IIS-Fundación Jiménez Díaz University Hospital, Madrid, Spain.,CIBERCV, Madrid, Spain
| | - A H Jan Danser
- Department of Pharmacology, Erasmus MC, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Pediatrics / Neonatology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
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12
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Ramu B, Houston BA, Tedford RJ. Pulmonary Vascular Disease: Hemodynamic Assessment and Treatment Selection—Focus on Group II Pulmonary Hypertension. Curr Heart Fail Rep 2018; 15:81-93. [DOI: 10.1007/s11897-018-0377-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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13
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Guazzi M, Labate V. Pulmonary Hypertension in Heart Failure Patients: Pathophysiology and Prognostic Implications. Curr Heart Fail Rep 2017; 13:281-294. [PMID: 27858232 DOI: 10.1007/s11897-016-0306-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pulmonary hypertension (PH) due to left heart disease (LHD), i.e., group 2 PH, is the most common reason for increased pressures in the pulmonary circuit. Although recent guidelines incorporate congenital heart disease in this classification, left-sided heart diseases of diastolic and systolic origin including valvular etiology are the vast majority. In these patients, an increased left-sided filling pressure triggers a multistage hemodynamic evolution that ends into right ventricular failure through an initial passive increase in pulmonary artery pressure complicated over time by pulmonary vasoconstriction, endothelial dysfunction, and remodeling of the small-resistance pulmonary arteries. Regardless of the underlying left heart pathology, when present, PH-LHD is associated with more severe symptoms, worse exercise tolerance, and outcome, especially when right ventricular dysfunction and failure are part of the picture. Compared with group 1 and other forms of pulmonary arterial hypertension, PH-LHD is more often seen in elderly patients with a higher prevalence of cardiovascular comorbidities and most, if not all, of the features of metabolic syndrome, especially in case of HF preserved ejection fraction. In this review, we provide an update on current knowledge and some potential challenges about the pathophysiology and established prognostic implications of group 2 PH in patients with HF of either preserved or reduced ejection fraction.
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Affiliation(s)
- Marco Guazzi
- University Cardiology Department, IRCCS Policlinico San Donato, University of Milano, Piazza Malan, 2, 20097, Milan, Italy.
| | - Valentina Labate
- University Cardiology Department, IRCCS Policlinico San Donato, University of Milano, Piazza Malan, 2, 20097, Milan, Italy
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14
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Wright SP, Moayedi Y, Foroutan F, Agarwal S, Paradero G, Alba AC, Baumwol J, Mak S. Diastolic Pressure Difference to Classify Pulmonary Hypertension in the Assessment of Heart Transplant Candidates. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.117.004077. [PMID: 28912262 DOI: 10.1161/circheartfailure.117.004077] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/15/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND The diastolic pressure difference (DPD) is recommended to differentiate between isolated postcapillary and combined pre-/postcapillary pulmonary hypertension (Cpc-PH) in left heart disease (PH-LHD). However, in usual practice, negative DPD values are commonly calculated, potentially related to the use of mean pulmonary artery wedge pressure (PAWP). We used the ECG to gate late-diastolic PAWP measurements. We examined the method's impact on calculated DPD, PH-LHD subclassification, hemodynamic profiles, and mortality. METHODS AND RESULTS We studied patients with advanced heart failure undergoing right heart catheterization to assess cardiac transplantation candidacy (N=141). Pressure tracings were analyzed offline over 8 to 10 beat intervals. Diastolic pulmonary artery pressure and mean PAWP were measured to calculate the DPD as per usual practice (diastolic pulmonary artery pressure-mean PAWP). Within the same intervals, PAWP was measured gated to the ECG QRS complex to calculate the QRS-gated DPD (diastolic pulmonary artery pressure-QRS-gated PAWP). Outcomes occurring within 1 year were collected retrospectively from chart review. Overall, 72 of 141 cases demonstrated PH-LHD. Within PH-LHD, the QRS-gated DPD yielded higher calculated DPD values (3 [-1 to 6] versus 0 [-4 to 3] mm Hg; P<0.01) and a greater proportion of Cpc-PH (24% versus 8%; P<0.01) versus the usual practice DPD. Cases reclassified as Cpc-PH based on QRS-gated DPD demonstrated higher pulmonary arterial pressures versus isolated postcapillary pulmonary hypertension (P<0.05). One-year mortality was similar between PH-LHD groups. CONCLUSIONS The DPD calculated in usual practice is underestimated in PH-LHD, which may classify Cpc-PH patients as isolated postcapillary pulmonary hypertension. The QRS-gated DPD reclassifies a subset of PH-LHD patients from isolated postcapillary pulmonary hypertension to Cpc-PH, which is characterized by an adverse hemodynamic profile.
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Affiliation(s)
- Stephen P Wright
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.)
| | - Yasbanoo Moayedi
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.)
| | - Farid Foroutan
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.)
| | - Suhail Agarwal
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.)
| | - Geraldine Paradero
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.)
| | - Ana C Alba
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.)
| | - Jay Baumwol
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.)
| | - Susanna Mak
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.).
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15
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Dupuis-Girod S, Cottin V, Shovlin CL. The Lung in Hereditary Hemorrhagic Telangiectasia. Respiration 2017; 94:315-330. [PMID: 28850955 DOI: 10.1159/000479632] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a dominantly inherited genetic vascular disorder with an estimated prevalence of 1 in 6,000, characterized by recurrent epistaxis, cutaneous telangiectasia, and arteriovenous malformations (AVMs) that affect many organs including the lungs, gastrointestinal tract, liver, and brain. Its diagnosis is based on the Curaçao criteria, and is considered definite if at least 3 of the 4 following criteria are fulfilled: (1) spontaneous and recurrent epistaxis, (2) telangiectasia, (3) a family history, and (4) pulmonary, liver, cerebral, spinal, or gastrointestinal AVMs. The focus of this review is on delineating how HHT affects the lung.
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Affiliation(s)
- Sophie Dupuis-Girod
- Service de génétique - centre de référence national pour la maladie de Rendu-Osler, Hôpital Femme-Mère-Enfants, Hospices Civils de Lyon, Bron, France
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16
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Clinical Relevance of Fluid Challenge in Patients Evaluated for Pulmonary Hypertension. Chest 2017; 151:119-126. [DOI: 10.1016/j.chest.2016.08.1439] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 07/13/2016] [Accepted: 08/01/2016] [Indexed: 01/04/2023] Open
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