Técnicas de imagen en la evaluación del corazón derecho y la circulación pulmonar

The association of Pulmonary Hypertension and right ventricular systolic function - updates in diagnosis and treatment

Right ventricular (RV) systolic function is an essential but neglected component in cardiac evaluation, and its importance to the contribution to overall cardiac function is undermined. It is not only sensitive to the effect of left heart valve disease but is also more sensitive to changes in pressure overload than the left ventricle. Pulmonary Hypertension is the common and well-recognized complication of RV systolic dysfunction. It is also the leading cause of pulmonary valve disease and right ventricular dysfunction. Patients with a high pulmonary artery pressure (PAP) and a low RV ejection fraction have a seven-fold higher risk of death than heart failure patients with a normal PAP and RV ejection fraction. Furthermore, it is an independent predictor of survival in these patients. In this review, we examine the association of right ventricular systolic function with Pulmonary Hypertension by focusing on various pathological and clinical manifestations while assessing their impact. We also explore new 2022 ESC/ERS guidelines for diagnosing and treating right ventricular dysfunction in Pulmonary Hypertension.

[Update on pediatric cardiology and congenital heart disease: imaging techniques, pulmonary arterial hypertension, hybrid treatment, and surgical treatment]

This article contains a review of the most significant contributions to pediatric cardiology and congenital heart disease reported in publications between September 2009 and August 2010. The review focuses on imaging techniques, new treatment for pulmonary arterial hypertension in pediatric patients, and therapy in general (e.g. hybrid treatment and surgical treatment). With regard to imaging techniques, the review highlights the increasing application of congenital heart disease diagnosis during fetal life, the introduction of new echocardiographic techniques (e.g. tissue Doppler imaging, two-dimensional speckle-tracking imaging and three-dimensional echocardiography) into routine clinical practice, and the growing use of cardiac CT and magnetic resonance imaging in diagnosis and the assessment of cardiac function, respectively. The role played by cardiac interventions continues to increase and cardiac surgery is becoming more advanced and has, in some cases, been combined with hybrid techniques. However, there are still a number of controversial issues in cardiac surgery that have not yet been resolved, such as whether or not fenestration should be used with Fontan surgery, the optimum type of correction for hypoplastic left heart syndrome, and the best conduit for pulmonary artery replacement.

[Pulmonary circulation: what has 2010 brought?]

In both thromboembolic disease and pulmonary hypertension, 2010 has been a prodigious year for interesting publications. Some data have helped to elucidate the factors associated with a greater risk of thromboembolic disease, such as long journeys and certain polymorphisms. New recommendations on diagnosis have been made, giving a greater role to computed tomography angiography. Magnetic resonance imaging is also gaining ground. More accurate risk evaluation is one of the objectives of the new guidelines of the European Society of Cardiology, which substitute some terms such as massive or submassive for high- and low-risk. Maintaining anticoagulation indefinitely in idiopathic pulmonary thromboembolism is recommended. Evidence on the efficacy of new drugs such as rivaroxaban, dabigatran and indraparinux is beginning to appear. In pulmonary hypertension, smoking seems to play a role as a risk factor. Some registries indicate that new treatments have not improved survival. Greater knowledge has been gained of the role of inflammation in the pathogenesis of the disease and a Spanish study supports the role of the 6-minute walk test in patient evaluation. Some drugs are highlighted in the literature. Imatinib is promising but probably only in some patients. Riociguat provides good results and inhaled treprostinil has emerged as a new option.

Factors affecting the response to exercise in patients with severe pulmonary arterial hypertension

INTRODUCTION

Ergospirometry objectively quantifies exercise capacity. Up until now, the response to exercise evaluated by ergospirometry in patients with pulmonary arterial hypertension has only been described in recently diagnosed.patients. Our aim is to describe the response to exercise in patients with severe pulmonary arterial hypertension under specific treatment and define which parameters determine their exercise capacity.

PATIENTS AND METHOD

A cross-sectional study was performed on 80 patients, 57 women, aged 45 (14), with severe pulmonary arterial hypertension (48 idiopathic, 14 related to toxic rapeseed oil, 13 to connective tissue disease, 5 to human immunodeficiency virus), mean pulmonary pressure at diagnosis 61(15)mmHg and after 49(33) months under treatment since diagnosis. Biomarkers were measured and echocardiography and ergospirometry were performed the same day.

RESULTS

Our patients, under specific treatment, showed the typical behaviour of patients with pulmonary arterial hypertension with less limitation of both aerobic capacity and ventilatory efficiency. Being male (p=0.004), high ventilatory equivalent for carbon dioxide at anaerobic threshold (p<0.001) or biomarkers (p=0.006) were the strongest predictors of impaired peak oxygen uptake in multivariate analysis, whereas for an impaired percentage achieved of predicted value were right ventricle diastolic diameter (p<0.001), months of treatment (p=0.01) and high ventilatory equivalent for CO(2) (p<0.001).

CONCLUSIONS

In pulmonary arterial hypertension, right ventricle dysfunction (expressed by its dilation or high NTproBNP) and impaired ventilatory inefficiency as well as being male or a short time under treatment can be considered as determining factors of impaired exercise capacity.

Current diagnostic and prognostic assessment of pulmonary Hypertension

Recently, our view of pulmonary hypertension has been changed by the significant progress made in understanding the pathobiology, epidemiology and prognosis of the disease. The increasing number of different conditions now associated with pulmonary hypertension and the appearance of new diagnostic techniques have led to a need for a systematic diagnostic approach and a new disease classification. This review article presents an update on developments in the epidemiology and pathobiology of pulmonary hypertension, on changes in the clinical classification of the disease, and on alterations in the diagnostic algorithm. In addition, it contains detailed descriptions of the treatment recommended for patients in whom an elevated systolic pulmonary pressure is discovered on echocardiography, of the differential diagnosis of pulmonary arterial hypertension and pulmonary hypertension associated with left heart disease, and of multifactorial approaches to determining prognosis, which are three of the most actively debated topics today. Finally, a care program for patients with pulmonary arterial hypertension is proposed.