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Levy D, Saura O, Lucenteforte M, Collado Lledó E, Demondion P, Hammoudi N, Assouline B, Petit M, Gautier M, Le Fevre L, Pineton de Chambrun M, Coutance G, Berg E, Chommeloux J, Schmidt M, Luyt CE, Lebreton G, Leprince P, Hékimian G, Combes A. Isoproterenol improves hemodynamics and right ventricle-pulmonary artery coupling after heart transplantation. Am J Physiol Heart Circ Physiol 2024; 327:H131-H137. [PMID: 38700470 DOI: 10.1152/ajpheart.00200.2024] [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: 04/01/2024] [Revised: 05/02/2024] [Accepted: 05/02/2024] [Indexed: 05/05/2024]
Abstract
Right ventricular failure (RVF) is a major cause of early mortality after heart transplantation (HT). Isoproterenol (Iso) has chronotropic, inotropic, and vasodilatory properties, which might improve right ventricle function in this setting. We aimed to investigate the hemodynamic effects of isoproterenol on patients with post-HT RVF. We conducted a 1-yr retrospective observational study including patients receiving isoproterenol (Iso) and dobutamine for early RVF after HT. A comprehensive multiparametric hemodynamic evaluation was performed successively three times: no isoproterenol, low doses: 0.025 µg/kg/min, and high doses: 0.05 µg/kg/min (henceforth, respectively, called no Iso, low Iso, and high Iso). From June 2022 to June 2023, 25 patients, median [interquartile range (IQR) 25-75] age 54 [38-61] yr, were included. Before isoproterenol was introduced, all patients received dobutamine, and 15 (60%) were on venoarterial extracorporeal membrane oxygenation (VA-ECMO). Isoproterenol significantly increased heart rate from 84 [77-99] (no Iso) to 91 [88-106] (low Iso) and 102 [90-122] beats/min (high Iso, P < 0.001). Similarly, cardiac index rose from 2.3 [1.4-3.1] to 2.7 [1.8-3.4] and 3 [1.9-3.7] L/min/m2 (P < 0.001) with a concomitant increase in indexed stroke volume (28 [17-34] to 31 [20-34] and 33 [23-35] mL/m2, P < 0.05). Effective pulmonary arterial elastance and pressures were not modified by isoproterenol. Pulmonary vascular resistance (PVR) tended to decrease from 2.9 [1.4-3.6] to 2.3 [1.3-3.5] wood units (WU), P = 0.06. Right ventricular ejection fraction/systolic pulmonary artery pressure (sPAP) evaluating right ventricle-pulmonary artery (RV-PA) coupling increased after isoproterenol from 0.8 to 0.9 and 1%·mmHg-1 (P = 0.001). In conclusion, in post-HT RVF, isoproterenol exhibits chronotropic and inotropic effects, thereby improving RV-PA coupling and resulting in a clinically relevant increase in the cardiac index.NEW & NOTEWORTHY This study offers a detailed and comprehensive hemodynamic investigation at the bedside, illustrating the favorable impact of isoproterenol on right ventricular-pulmonary arterial coupling and global hemodynamics. It elucidates the physiological effects of an underused inotropic strategy in a critical clinical scenario. By enhancing cardiac hemodynamics, isoproterenol has the potential to expedite right ventricular recovery and mitigate primary graft dysfunction, thereby reducing the duration of mechanical support and intensive care unit stay posttransplantation.
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Affiliation(s)
- David Levy
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Ouriel Saura
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Manuela Lucenteforte
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Department of Health Sciences, University of Milan, Milano, Italy
| | - Elena Collado Lledó
- Acute Cardiovascular Care Unit, Department of Cardiology, Hospital Germans Trias i Pujol, Barcelona, Spain
| | - Pierre Demondion
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Chirurgie Cardiaque et Thoracique, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Nadjib Hammoudi
- Sorbonne Université, ACTION Study Group, INSERM UMR_S 1166 and Hôpital Pitié-Salpêtrière (Assistance Publique-Hôpitaux de Paris), Boulevard de l'hôpital, Paris, France
| | - Benjamin Assouline
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
- Intensive Care Medicine Unit, Division of Intensive Care, Department of Acute Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Matthieu Petit
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Melchior Gautier
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Lucie Le Fevre
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Marc Pineton de Chambrun
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
- Service de Médecine Interne 2, Centre de Référence Lupus Systémique, SAPL et Autres Maladies Auto-immunes et Systémiques Rares, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Guillaume Coutance
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Chirurgie Cardiaque et Thoracique, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Elodie Berg
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Chirurgie Cardiaque et Thoracique, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Juliette Chommeloux
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Matthieu Schmidt
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Charles-Edouard Luyt
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Guillaume Lebreton
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Chirurgie Cardiaque et Thoracique, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Pascal Leprince
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Chirurgie Cardiaque et Thoracique, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Guillaume Hékimian
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
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2
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Manouras A, Lund LH, Nagy AI, Johnson J. Insights into RC time curve fit analysis of pulmonary artery pressure decay. BMC Pulm Med 2024; 24:295. [PMID: 38914995 PMCID: PMC11197313 DOI: 10.1186/s12890-024-03107-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 06/18/2024] [Indexed: 06/26/2024] Open
Abstract
The notion of a constant relationship between resistance and capacitance (RC time) in the pulmonary circulation has been challenged by more recent research. The RC time can be obtained using either a simplified empirical approach or a semilogarithmic equation. Although direct curve-fit analysis is a feasible and ostensibly reference approach for RC analysis, it remains largely unexplored. We aimed to study the relationship between various RC methods in different states of pulmonary hemodynamics. Methods In total, 182 patients underwent clinically indicated right heart catheterization. The pressure curves were exported and processed using the MATLAB software. We calculated the RC time using the empirical method (RCEST), semilogarithmic approach (RCSL), and direct measurement of curve fit (RCFIT). Results Among 182 patients, 137 had pulmonary hypertension due to left heart disease (PH-LHD), 35 had pulmonary arterial hypertension (PAH), and 10 demonstrated normal hemodynamics (non-PH). RCEST consistently overestimated the RCFIT and RCSL measurements by a mean of 75%. With all three methods, the RC values were longer in the PAH (RCFIT = 0.36 ± 0.14 s) than in the PH-LHD (0.27 ± 0.1 s) and non-PH (0.27 ± 0.09 s) groups (p < 0.001). Although the RCSL and RCFIT values were similar among the three subgroups, they exhibited broad limits of agreement. Finally, the RCEST demonstrated a strong discriminatory ability (AUC = 0.86, p < 0.001, CI = 0.79-0.93) in identifying PAH. Conclusion RC time in PAH patients was substantially prolonged compared to that in PH-LHD and non-PH patients. The use of the empirical formula yielded systematic RC overestimation. In contrast, the semilogarithmic analysis provided reliable RC estimates, particularly for group comparisons.
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Affiliation(s)
- Aristomenis Manouras
- Heart and Vascular Center, Unit of Heart Failure, Arrhythmia and GUCH, Karolinska University Hospital, Stockholm, Sweden.
- Department of Medicine, Solna Karolinska Institutet, 17177, Stockholm, Sweden.
| | - Lars H Lund
- Heart and Vascular Center, Unit of Heart Failure, Arrhythmia and GUCH, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Solna Karolinska Institutet, 17177, Stockholm, Sweden
| | - Anikó Ilona Nagy
- Department of Medicine, Solna Karolinska Institutet, 17177, Stockholm, Sweden
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Jonas Johnson
- Centre for Fetal Medicine Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
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Wang H, Ma J, Han L, Tan T, Xie W, Tian M, Tujia Z, Li Y, Liu X, Liu X, Yuan H, Chen J. Ventricular Morphology and Outcomes in Fontan Circulation without Hypoplastic Left Heart Syndrome: A Single-Center's Experience. Rev Cardiovasc Med 2024; 25:193. [PMID: 39076343 PMCID: PMC11270118 DOI: 10.31083/j.rcm2506193] [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: 12/31/2023] [Revised: 02/09/2024] [Accepted: 02/26/2024] [Indexed: 07/31/2024] Open
Abstract
Background The impact of dominant ventricular morphology on Fontan patient outcomes remain controversial. This study evaluates long-term results of right ventricle (RV) dominance versus left ventricle (LV) dominance in Fontan circulation without hypoplastic left heart syndrome (HLHS). Methods We retrospectively examined 323 Fontan operations from our center. To minimize pre- and intra-Fontan heterogeneity, 42 dominant RV patients were matched with 42 dominant LV patients using propensity score matching, allowing for a comparative analysis of outcomes between groups. Results The mean follow-up was 8.0 ± 4.6 years for matched RV dominant and 6.5 ± 4.7 years for matched LV dominant group (p > 0.05), showing no significant difference. The cumulative incidence of moderate or greater atrioventricular valve regurgitation was also comparable between the two groups (p > 0.05). Similarly, 10-year freedom from death or transplantation following the Fontan operation was 84% ± 7% in the matched dominant RV group, similar to 81% ± 7% in the matched dominant LV group (p > 0.05). The 10-year freedom from Fontan failure was 78% ± 8% in the matched dominant RV group, also similar to 75% ± 8% in the matched dominant LV group (p > 0.05). Multivariate analysis did not identify RV dominance as a risk factor for Fontan failure (p > 0.05). Conclusions In the pre- and intra-Fontan context, RV dominance demonstrated similar and comparable long-term outcomes compared to LV dominance in non-HLHS Fontan circulation.
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Affiliation(s)
- Han Wang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080 Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, 510080 Guangzhou, Guangdong, China
| | - Jianrui Ma
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080 Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, 510080 Guangzhou, Guangdong, China
- Shantou University Medical College, 515041 Shantou, Guangdong, China
| | - Linjiang Han
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080 Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, 510080 Guangzhou, Guangdong, China
| | - Tong Tan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080 Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, 510080 Guangzhou, Guangdong, China
- Department of Cardiovascular Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vascular Diseases, 100029 Beijing, China
| | - Wen Xie
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080 Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, 510080 Guangzhou, Guangdong, China
| | - Miao Tian
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080 Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, 510080 Guangzhou, Guangdong, China
| | - Zichao Tujia
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080 Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, 510080 Guangzhou, Guangdong, China
| | - Ying Li
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080 Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, 510080 Guangzhou, Guangdong, China
| | - Xiang Liu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080 Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, 510080 Guangzhou, Guangdong, China
| | - Xiaobing Liu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080 Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, 510080 Guangzhou, Guangdong, China
| | - Haiyun Yuan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080 Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, 510080 Guangzhou, Guangdong, China
| | - Jimei Chen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080 Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, 510080 Guangzhou, Guangdong, China
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Bou Chaaya RG, Hatab T, Samimi S, Qamar F, Kharsa C, Aoun J, Faza N, Little SH, Atkins MD, Reardon MJ, Kleiman NS, Nagueh SF, Zoghbi WA, Guha A, Zaid S, Goel SS. Prognostic Value of Right Ventricular Afterload in Patients Undergoing Mitral Transcatheter Edge-to-Edge Repair. J Am Heart Assoc 2024; 13:e033510. [PMID: 38567665 PMCID: PMC11262498 DOI: 10.1161/jaha.123.033510] [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: 11/10/2023] [Accepted: 01/25/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Pulmonary hypertension (PH) and secondary mitral regurgitation (MR) are associated with adverse outcomes after mitral transcatheter edge-to-edge repair. We aim to study the prognostic value of invasively measured right ventricular afterload in patients undergoing mitral transcatheter edge-to-edge repair. METHODS AND RESULTS We identified patients who underwent right heart catheterization ≤1 month before transcatheter edge-to-edge repair. The end points were all-cause mortality and a composite of mortality and heart failure hospitalization at 2 years. Using the receiver operating characteristic curve-derived threshold of 0.6 for pulmonary effective arterial elastance ([Ea], pulmonary artery systolic pressure/stroke volume), patients were stratified into 3 profiles based on PH severity (low elastance [HE]: Ea <0.6/mean pulmonary artery pressure (mPAP)) <35; High Elastance with No/Mild PH (HE-): Ea ≥0.6/mPAP <35; and HE with Moderate/Severe PH (HE+): Ea ≥0.6/mPAP ≥35) and MR pathogenesis (Primary MR [PMR])/low elastance, PMR/HE, and secondary MR). The association between this classification and clinical outcomes was examined using Cox regression. Among 114 patients included, 50.9% had PMR. Mean±SD age was 74.7±10.6 years. Patients with Ea ≥0.6 were more likely to have diabetes, atrial fibrillation, New York Heart Association III/IV status, and secondary MR (all P<0.05). Overall, 2-year cumulative survival was 71.1% and was lower in patients with secondary MR and mPAP ≥35. Compared with patients with low elastance, cumulative 2-year event-free survival was significantly lower in HE- and HE+ patients (85.5% versus 50.4% versus 41.0%, respectively, P=0.001). Also, cumulative 2-year event-free survival was significantly higher in patients with PMR/low elastance when compared with PMR/HE and patients with secondary mitral regurgitation (85.5% versus 55.5% versus 46.1%, respectively, P=0.005). CONCLUSIONS Assessment of the preprocedural cardiopulmonary profile based on mPAP, MR pathogenesis, and Ea guides patient selection by identifying hemodynamic features that indicate likely benefit from mitral-transcatheter edge-to-edge repair in PH or lack thereof.
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Affiliation(s)
| | - Taha Hatab
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | - Sahar Samimi
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | - Fatima Qamar
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | - Chloe Kharsa
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | - Joe Aoun
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | - Nadeen Faza
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | | | - Marvin D. Atkins
- Department of Cardiovascular SurgeryHouston Methodist HospitalHoustonTX
| | | | - Neal S. Kleiman
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | | | | | - Ashrith Guha
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | - Syed Zaid
- Department of CardiologyBaylor School of Medicine and the Michael E DeBakey VAMCHoustonTX
| | - Sachin S. Goel
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
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5
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Wright SP, Dawkins TG. How preserved is right ventricular reserve in hypoxia? J Physiol 2024. [PMID: 38477030 DOI: 10.1113/jp286397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 02/28/2024] [Indexed: 03/14/2024] Open
Affiliation(s)
- Stephen P Wright
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, BC, Canada
| | - Tony G Dawkins
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, BC, Canada
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Lamberti KK, Keller SP, Edelman ER. Dynamic load modulation predicts right heart tolerance of left ventricular cardiovascular assist in a porcine model of cardiogenic shock. Sci Transl Med 2024; 16:eadk4266. [PMID: 38354226 DOI: 10.1126/scitranslmed.adk4266] [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: 09/07/2023] [Accepted: 01/24/2024] [Indexed: 02/16/2024]
Abstract
Ventricular assist devices (VADs) offer mechanical support for patients with cardiogenic shock by unloading the impaired ventricle and increasing cardiac outflow and subsequent tissue perfusion. Their ability to adjust ventricular assistance allows for rapid and safe dynamic changes in cardiac load, which can be used with direct measures of chamber pressures to quantify cardiac pathophysiologic state, predict response to interventions, and unmask vulnerabilities such as limitations of left-sided support efficacy due to intolerance of the right heart. We defined hemodynamic metrics in five pigs with dynamic peripheral transvalvular VAD (pVAD) support to the left ventricle. Metrics were obtained across a spectrum of disease states, including left ventricular ischemia induced by titrated microembolization of a coronary artery and right ventricular strain induced by titrated microembolization of the pulmonary arteries. A sweep of different pVAD speeds confirmed mechanisms of right heart decompensation after left-sided support and revealed intolerance. In contrast to the systemic circulation, pulmonary vascular compliance dominated in the right heart and defined the ability of the right heart to adapt to left-sided pVAD unloading. We developed a clinically accessible metric to measure pulmonary vascular compliance at different pVAD speeds that could predict right heart efficiency and tolerance to left-sided pVAD support. Findings in swine were validated with retrospective hemodynamic data from eight patients on pVAD support. This methodology and metric could be used to track right heart tolerance, predict decompensation before right heart failure, and guide titration of device speed and the need for biventricular support.
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Affiliation(s)
- Kimberly K Lamberti
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Steven P Keller
- Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MA 21205, USA
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Bachman TN, Nouraie SM, Williams LE, Boisen ML, Kim K, Borovetz HS, Schaub R, Kormos RL, Simon MA. Feasibility of a Composite Measure of Pulmonary Vascular Impedance and Application to Patients with Chronic RV Failure Post LVAD Implant. Cardiovasc Eng Technol 2024; 15:1-11. [PMID: 38129334 DOI: 10.1007/s13239-023-00671-5] [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: 12/23/2022] [Accepted: 06/20/2023] [Indexed: 12/23/2023]
Abstract
Pulmonary vascular impedance (PVZ) describes RV afterload in the frequency domain and has not been studied extensively in LVAD patients. We sought to determine (1) feasibility of calculating a composite (c)PVZ using standard of care (SoC), asynchronous, pulmonary artery pressure (PAP) and flow (PAQ) waveforms; and (2) if chronic right ventricular failure (RVF) post-LVAD implant was associated with changes in perioperative cPVZ.PAP and PAQ were obtained via SoC procedures at three landmarks: T(1), Retrospectively, pre-operative with patient conscious; and T(2) and T(3), prospectively with patient anesthetized, and either pre-sternotomy or chest open with LVAD, respectively. Additional PAP's were taken at T(4), following chest closure; and T(5), 4-24 h post chest closure. Harmonics (z) were calculated by Fast Fourier Transform (FFT) with cPVZ(z) = FFT(PAP)/FFT(PAQ). Total pulmonary resistance Z(0); characteristic impedance Zc, mean of cPVZ(2-4); and vascular stiffness PVS, sum of cPVZ(1,2), were compared at T(1,2,3) between +/-RVF groups.Out of 51 patients, nine experienced RVF. Standard hemodynamics and changes in cPVZ-derived parameters were not significant between groups at any T.In conclusion, cPVZ calculated from SoC measures is possible. Although data that could be obtained were limited it suggests no difference in RV afterload for RVF patients post-implant. If confirmed in larger studies, focus should be placed on cardiac function in these subjects.
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Affiliation(s)
- Timothy N Bachman
- Dept. of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA.
| | - S M Nouraie
- Dept. Of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - L E Williams
- Dept. of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - M L Boisen
- Dept. of Anesthesia, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - K Kim
- Dept. of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - H S Borovetz
- Dept. of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - R Schaub
- Dept. of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - R L Kormos
- Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - M A Simon
- Division of Cardiology, Dept. of Medicine, University of California, San Francisco, San Francisco, CA, United States
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Osman S, Girdharry NR, Karvasarski E, Bentley RF, Wright SP, Sharif N, McInnis M, Granton JT, dePerrot M, Mak S. Exercise and pulsatile pulmonary vascular loading in chronic thromboembolic pulmonary disease. Pulm Circ 2024; 14:e12331. [PMID: 38249723 PMCID: PMC10799664 DOI: 10.1002/pul2.12331] [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: 03/21/2023] [Revised: 12/01/2023] [Accepted: 12/19/2023] [Indexed: 01/23/2024] Open
Abstract
Chronic thromboembolic pulmonary disease (CTEPD) is characterized by organized nonresolving thrombi in pulmonary arteries (PA). In CTEPD with pulmonary hypertension (PH), chronic thromboembolic PH (CTEPH), early wave reflection results in abnormalities of pulsatile afterload and augmented PA pressures. We hypothesized that exercise during right heart catheterization (RHC) would elicit more frequent elevations of pulsatile vascular afterload than resistive elevations in patients with CTEPD without PH. The interdependent physiology of pulmonary venous and PA hemodynamics was also evaluated. Consecutive patients with CTEPD without PH (resting mean PA pressure ≤20 mmHg) undergoing an exercise RHC were identified. Latent resistive and pulsatile abnormalities of pulmonary vascular afterload were defined as an exercise mean PA pressure/cardiac output >3 WU, and PA pulse pressure to PA wedge pressure (PA PP/PAWP) ratio >2.5, respectively. Forty-five patients (29% female, 53 ± 14 years) with CTEPD without PH were analyzed. With exercise, 19 patients had no abnormalities (ExNOR), 26 patients had abnormalities (ExABN) of pulsatile (20), resistive (2), or both (4) elements of pulmonary vascular afterload. Exercise elicited elevations of pulsatile afterload (53%) more commonly than resistive afterload (13%) (p < 0.001). ExABN patients had lower PA compliance and higher pulmonary vascular resistance at rest and exercise and prolonged resistance-compliance time product at rest. The physiological relationship between changes in PA pressures relative to PAWP was disrupted in the ExABN group. In CTEPD without PH, exercise RHC revealed latent pulmonary vascular afterload elevations in 58% of patients with more frequent augmentation of pulsatile than resistive pulmonary vascular afterload.
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Affiliation(s)
- Sinan Osman
- Division of CardiologyMount Sinai Hospital/University Health NetworkTorontoOntarioCanada
- Institute of Medical ScienceUniversity of TorontoTorontoOntarioCanada
| | - Natasha R. Girdharry
- Division of CardiologyMount Sinai Hospital/University Health NetworkTorontoOntarioCanada
- Institute of Medical ScienceUniversity of TorontoTorontoOntarioCanada
| | - Elizabeth Karvasarski
- Division of CardiologyMount Sinai Hospital/University Health NetworkTorontoOntarioCanada
- Institute of Medical ScienceUniversity of TorontoTorontoOntarioCanada
| | - Robert F. Bentley
- Faculty of Kinesiology and Physical EducationUniversity of TorontoTorontoOntarioCanada
| | - Stephen P. Wright
- School of Health and Exercise Sciences, Centre for Heart, Lung and Vascular HealthUniversity of British ColumbiaKelownaBritish ColumbiaCanada
| | - Nadia Sharif
- Department of Medicine, Division of RespirologyUniversity Health NetworkTorontoOntarioCanada
| | - Micheal McInnis
- Department of Medical ImagingUniversity of TorontoTorontoOntarioCanada
| | - John T. Granton
- Department of Medicine, Division of RespirologyUniversity Health NetworkTorontoOntarioCanada
| | - Marc dePerrot
- Department of Surgery, Division of Thoracic SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Susanna Mak
- Division of CardiologyMount Sinai Hospital/University Health NetworkTorontoOntarioCanada
- Institute of Medical ScienceUniversity of TorontoTorontoOntarioCanada
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9
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Bouchez S, Erb J, Foubert L, Mauermann E. Pressure-Volume Loops for Reviewing Right Ventricular Physiology and Failure in the Context of Left Ventricular Assist Device Implantation. Semin Cardiothorac Vasc Anesth 2023; 27:283-291. [PMID: 37654159 DOI: 10.1177/10892532231198797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Right ventricular (RV) function is complex as a number of determinants beyond preload, inotropy and afterload play a fundamental role. In particular, arterial elastance (Ea), ventriculo-arterial coupling (VAC), and (systolic) ventricular interdependence play a vital role for the right ventricle. Understanding and actively visualizing these interactions in the failing RV as well as in the altered hemodynamic and morphological situation of left ventricular assist device (LVAD) implantation may aid clinicians in their understanding of RV dysfunction and failure. While, admittedly, hard data is scarce and invasive pressure-volume loop measurements will not become routine in cardiac surgery, we hope that clinicians will benefit from the comprehensive, simulation-based review of RV pathology. In particular, the aim of this article is to first, address and clarify the pathophysiologic hemodynamic factors that lead to RV dysfunction and then, second, expand upon this basis examining the changes occurring by LVAD implantation. This is illustrated using Harvi software which shows elastance, ventricular arterial coupling, and ventricular interdependence by simultaneously showing pressure volume loops of the right and left ventricle.
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Affiliation(s)
- Stefaan Bouchez
- Department of Anesthesiology and Intensive Care, OLV Clinic, Aalst, Belgium
| | - Joachim Erb
- Department for Anesthesiology, Intermediate Medical Care, Prehospital Emergency Medicine, and Pain Therapy, Basel University Hospital, Basel, Switzerland
| | - Luc Foubert
- Department of Anesthesiology and Intensive Care, OLV Clinic, Aalst, Belgium
| | - Eckhard Mauermann
- Department of Anesthesiology, Zurich City Hospital, Zurich, Switzerland
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10
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Choubey M, Kothari SS, Gupta SK, Ramakrishnan S, Saxena A. Pulmonary arterial compliance in patients of CHD with increased pulmonary blood flow. Cardiol Young 2023; 33:1889-1895. [PMID: 36325920 DOI: 10.1017/s1047951122003341] [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] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Pulmonary arterial compliance, the dynamic component of pulmonary vasculature, remains inadequately studied in patients with left to right shunts. We sought to study the pulmonary arterial compliance in patients with left to right shunt lesions and its utility in clinical decision-making. MATERIALS AND METHODS In this single-centre retrospective study, we reviewed cardiac catheterisation data of consecutive patients of left to right shunt lesions catheterised over one year. In addition to the various other parameters, pulmonary arterial compliance was calculated, as indexed pulmonary flow (Qpi) / (Heart rate × pulse pressure in the pulmonary artery). RC time was also calculated, as the product of pulmonary arterial compliance and pulmonary vascular resistance index. Patients were divided into "operable," "borderline," and "inoperable" based on the decision of the treating team, and the pulmonary arterial compliance values were evaluated in these groups to study if it can be utilised to refine the operability decision. RESULTS 298 patients (Median age 16 years, 56% <18 years) with various acyanotic shunt lesions were included. Overall, the pulmonary arterial compliance varied with Qpi, pulmonary artery mean pressure, and pulmonary vascular resistance index, but did not vary with age, type of lesion, or transpulmonary gradients. The median pulmonary arterial compliance in patients with normal pulmonary artery pressure (Mean pulmonary artery pressure less than 20 mmHg) was 4.1 ml/mmHg/m2 (IQR 3.2). The median pulmonary arterial compliance for operable patients was 2.67 ml/mmHg/m2 (IQR 2.2). Median pulmonary arterial compliance was significantly lower in both inoperable (0.52 ml/mmHg/m2, IQR 0.34) and borderline (0.80 ml/mmHg/m2, IQR 0.36) groups when compared to operable patients (p < 0.001). A pulmonary arterial compliance value lower than 1.18 ml/mmHg/m2 identified inoperable patients with high sensitivity and specificity (95%, AUC 0.99). However, in borderline cases, assessment by this value did not agree with empirical clinical assessment.The median RC time for the entire study population was 0.47 S (IQR 0.30). RC time in operable patients was significantly lower than that in the inoperable patients (Median 0.40 IQR 0.23 in operable, 0.73 0.25 in inoperable patients (p < 0.001). CONCLUSIONS Addition of pulmonary arterial compliance to the routine haemodynamic assessment of patients with shunt lesions may improve our understanding of the pulmonary circulation and may have clinical utility.
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Affiliation(s)
- Mrigank Choubey
- Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shyam S Kothari
- Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh K Gupta
- Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Anita Saxena
- Cardiology, All India Institute of Medical Sciences, New Delhi, India
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11
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Wang RS, Huang S, Waldo SW, Hess E, Gokhale M, Johnson SW, Zeder K, Choudhary G, Leopold JA, Oldham WM, Kovacs G, Freiberg MS, Tedford RJ, Maron BA, Brittain EL. Elevated Pulmonary Arterial Compliance Is Associated with Survival in Pulmonary Hypertension: Results from a Novel Network Medicine Analysis. Am J Respir Crit Care Med 2023; 208:312-321. [PMID: 37276608 PMCID: PMC10395727 DOI: 10.1164/rccm.202211-2097oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 05/31/2023] [Indexed: 06/07/2023] Open
Abstract
Rationale: Predictors of adverse outcome in pulmonary hypertension (PH) are well established; however, data that inform survival are lacking. Objectives: We aim to identify clinical markers and therapeutic targets that inform the survival in PH. Methods: We included data from patients with elevated mean pulmonary artery pressure (mPAP) diagnosed by right heart catheterization in the U.S. Veterans Affairs system (October 1, 2006-September 30, 2018). Network medicine framework was used to subgroup patients when considering an N of 79 variables per patient. The results informed outcome analyses in the discovery cohort and a sex-balanced validation right heart catheterization cohort from Vanderbilt University (September 24, 1998-December 20, 2013). Measurements and Main Results: From an N of 4,737 complete case patients with mPAP of 19-24 mm Hg, there were 21 distinct subgroups (network modules) (all-cause mortality range = 15.9-61.2% per module). Pulmonary arterial compliance (PAC) drove patient assignment to modules characterized by increased survival. When modeled continuously in patients with mPAP ⩾19 mm Hg (N = 37,744; age, 67.2 yr [range = 61.7-73.8 yr]; 96.7% male; median follow-up time, 1,236 d [range = 570-1,971 d]), the adjusted all-cause mortality hazard ratio was <1.0 beginning at PAC ⩾3.0 ml/mm Hg and decreased progressively to ∼7 ml/mm Hg. A protective association between PAC ⩾3.0 ml/mm Hg and mortality was also observed in the validation cohort (N = 1,514; age, 60.2 yr [range = 49.2-69.1 yr]; 48.0% male; median follow-up time, 2,485 d [range = 671-3,580 d]). The association was strongest in patients with precapillary PH at the time of catheterization, in whom 41% (95% confidence interval, 0.55-0.62; P < 0.001) and 49% (95% confidence interval, 0.38-0.69; P < 0.001) improvements in survival were observed for PAC ⩾3.0 versus <3.0 ml/mm Hg in the discovery and validation cohorts, respectively. Conclusions: These data identify elevated PAC as an important parameter associated with survival in PH. Prospective studies are warranted that consider PAC ⩾3.0 ml/mm Hg as a therapeutic target to achieve through proven interventions.
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Affiliation(s)
- Rui-Sheng Wang
- Division of Cardiovascular Medicine
- Channing Division of Network Medicine, and
| | | | - Stephen W. Waldo
- Department of Medicine, Cardiology Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado
- Veterans Affairs Clinical Assessment, Reporting, and Tracking Program, Veterans Health Administration Office of Quality and Patient Safety, Washington, DC
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Edward Hess
- Department of Medicine, Cardiology Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Madhura Gokhale
- Department of Medicine, Cardiology Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Shelsey W. Johnson
- Department of Pulmonary and Critical Care, Boston Medical Center, Boston, Massachusetts
| | - Katarina Zeder
- Department of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Gaurav Choudhary
- Providence Veterans Affairs Medical Center and Division of Cardiovascular Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - William M. Oldham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Gabor Kovacs
- Department of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Matthew S. Freiberg
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Centers (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Ryan J. Tedford
- Division of Cardiology, Medical Department of Medicine, University of South Carolina, Charleston, South Carolina; and
| | - Bradley A. Maron
- Division of Cardiovascular Medicine
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Evan L. Brittain
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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12
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Gard EK, Beale AL, Telles F, Silvestry FE, Hanff T, Hummel SL, Litwin SE, Petrie MC, Shah SJ, Borlaug BA, Burkhoff D, Komtebedde J, Kaye DM, Nanayakkara S. Left atrial enlargement is associated with pulmonary vascular disease in heart failure with preserved ejection fraction. Eur J Heart Fail 2023; 25:806-814. [PMID: 36847073 PMCID: PMC10625803 DOI: 10.1002/ejhf.2805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/22/2023] [Accepted: 02/17/2023] [Indexed: 03/01/2023] Open
Abstract
AIMS Elevated left atrial (LA) pressure is a pathophysiologic hallmark of heart failure with preserved ejection fraction (HFpEF). Chronically elevated LA pressure leads to LA enlargement, which may impair LA function and increase pulmonary pressures. We sought to evaluate the relationship between LA volume and pulmonary arterial haemodynamics in patients with HFpEF. METHODS AND RESULTS Data from 85 patients (aged 69 ± 8 years) who underwent exercise right heart catheterization and echocardiography were retrospectively analysed. All had symptoms of heart failure, left ventricular ejection fraction ≥50% and haemodynamic features of HFpEF. Patients were divided into LA volume index-based tertiles (≤34 ml/m2 , >34 to ≤45 ml/m2 , >45 ml/m2 ). A subgroup analysis was performed in patients with recorded LA global reservoir strain (n = 60), with reduced strain defined as ≤24%. Age, sex, body surface area and left ventricular ejection fraction were similar between volume groups. LA volume was associated with blunted increases in cardiac output with exercise (padjusted <0.001), higher resting mean pulmonary artery pressure (padjusted = 0.003), with similar wedge pressure (padjusted = 1). Pulmonary vascular resistance (PVR) increased with increasing LA volume (padjusted <0.001). Larger LA volumes featured reduced LA strain (padjusted <0.001), with reduced strain associated with reduced PVR-compliance time (0.34 [0.28-0.40] vs. 0.38 [0.33-0.43], p = 0.03). CONCLUSION Increasing LA volume may be associated with more advanced pulmonary vascular disease in HFpEF, featuring higher PVR and pulmonary pressures. Reduced LA function, worse at increasing LA volumes, is associated with a disrupted PVR-compliance relationship, further augmenting impaired pulmonary haemodynamics.
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Affiliation(s)
| | | | - Fernando Telles
- Heart Failure Research Group, Baker Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | | | - Thomas Hanff
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott L. Hummel
- University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | | | | | - Sanjiv J. Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Dan Burkhoff
- Cardiovascular Research Foundation, New York, NY, USA
| | | | - David M. Kaye
- Alfred Hospital, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart & Diabetes Institute, Melbourne, Victoria, Australia
- Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Shane Nanayakkara
- Alfred Hospital, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart & Diabetes Institute, Melbourne, Victoria, Australia
- Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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13
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Ahsan SA, Laird R, Dooley C, Akbar S, Sweeney J, Ohira S, Kai M, Levine A, Gass AL, Frishman WH, Aronow WS, Lanier GM. An Update on the Diagnosis and Management of Acute Right Heart Failure. Cardiol Rev 2023:e000538. [PMID: 36847512 DOI: 10.1097/crd.0000000000000538] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Right ventricular (RV) dysfunction and resultant acute right heart failure (ARHF) is a rapidly growing field of interest, driven by increasing appreciation of its contribution to heart failure morbidity and mortality. Understanding of ARHF pathophysiology has advanced dramatically over recent years and can be broadly described as RV dysfunction related to acute changes in RV afterload, contractility, preload, or left ventricular dysfunction. There are several diagnostic clinical signs and symptoms as well as imaging and hemodynamic assessments that can provide insight into the degree of RV dysfunction. Medical management is tailored to the different causative pathologies, and in cases of severe or end-stage dysfunction, mechanical circulatory support can be utilized. In this review, we describe the pathophysiology of ARHF, how its diagnosis is established by clinical signs and symptoms and imaging findings, and provide an overview of treatment options, both medical and mechanical.
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Affiliation(s)
- Syed Adeel Ahsan
- From the Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Rachel Laird
- Department of Medicine, Houston Methodist Hospital, Houston, TX
| | - Caroline Dooley
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Sara Akbar
- Department of pulmonary and critical care medicine, Spectrum Health/Michigan State University, Detroit, MI
| | - James Sweeney
- Division of Cardiology, Hackensack Meridian Jersey Shore University Medical Center, Neptune, NJ
| | - Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
| | - Avi Levine
- Departments of Cardiology and Medicine Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Alan L Gass
- Departments of Cardiology and Medicine Westchester Medical Center and New York Medical College, Valhalla, NY
| | - William H Frishman
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- Departments of Cardiology and Medicine Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Gregg M Lanier
- Departments of Cardiology and Medicine Westchester Medical Center and New York Medical College, Valhalla, NY
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14
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Haloot J, Mahmoud M, Prasad A, Anderson AS, Aslam MI. Management of Post-Myocardial Infarction Right Ventricular Failure. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100526. [PMID: 39132546 PMCID: PMC11308243 DOI: 10.1016/j.jscai.2022.100526] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/05/2022] [Accepted: 10/11/2022] [Indexed: 08/13/2024]
Abstract
Right ventricular failure (RVF) due to an acute myocardial infarction (MI) has been associated with high morbidity and mortality. Initial treatment is guided by early recognition and prompt revascularization. Current management of post-MI RVF is built upon expert consensus and is also informed by RVF from other etiologies, including massive pulmonary embolism, left ventricular assist device-associated right ventricular dysfunction, postcardiotomy shock, etc.; this speaks to the limited data available on the specific management of RVF in acute MI. The goal of this review is to discuss the current literature on the pathophysiology, general management considerations, interventional management, hemodynamic monitoring, medical management, and mechanical circulatory support of MI-induced RVF.
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Affiliation(s)
- Justin Haloot
- Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Mohamed Mahmoud
- Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Anand Prasad
- Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Allen S. Anderson
- Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - M. Imran Aslam
- Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas
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15
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Glass A, McCall P, Arthur A, Mangion K, Shelley B. Pulmonary artery wave reflection and right ventricular function after lung resection. Br J Anaesth 2023; 130:e128-e136. [PMID: 36115714 PMCID: PMC9875909 DOI: 10.1016/j.bja.2022.07.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/02/2022] [Accepted: 07/26/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Lung resection has been shown to impair right ventricular function. Although conventional measures of afterload do not change, surgical ligation of a pulmonary artery branch, as occurs during lobectomy, can create a unilateral proximal reflection site, increasing wave reflection (pulsatile component of afterload) and diverting blood flow through the contralateral pulmonary artery. We present a cardiovascular magnetic resonance imaging (MRI) observational cohort study of changes in wave reflection and right ventricular function after lung resection. METHODS Twenty-seven patients scheduled for open lobectomy for suspected lung cancer underwent cardiovascular MRI preoperatively, on postoperative Day 2, and at 2 months. Wave reflection was assessed in the left and right pulmonary arteries (operative and non-operative, as appropriate) by wave intensity analysis and calculation of wave reflection index. Pulmonary artery blood flow distribution was calculated as percentage of total blood flow travelling in the non-operative pulmonary artery. Right ventricular function was assessed by ejection fraction and strain analysis. RESULTS Operative pulmonary artery wave reflection increased from 4.3 (2.1-8.8) % preoperatively to 9.5 (4.9-14.9) % on postoperative Day 2 and 8.0 (2.3-11.7) % at 2 months (P<0.001) with an associated redistribution of blood flow towards the nonoperative pulmonary artery (r>0.523; P<0.010). On postoperative Day 2, impaired right ventricular ejection fraction was associated with increased operative pulmonary artery wave reflection (r=-0.480; P=0.028) and pulmonary artery blood flow redistribution (r=-0.545; P=0.011). At 2 months, impaired right ventricular ejection fraction and right ventricular strain were associated with pulmonary artery blood flow redistribution (r=-0.634, P=0.002; r=0.540, P=0.017). CONCLUSIONS Pulsatile afterload increased after lung resection. The unilateral increase in operative pulmonary artery wave reflection resulted in redistribution of blood flow through the nonoperative pulmonary artery and was associated with right ventricular dysfunction. CLINICAL TRIAL REGISTRATION NCT01892800.
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Affiliation(s)
- Adam Glass
- Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK,School of Anaesthesia, Northern Ireland Medical and Dental Training Agency, Belfast, UK,Corresponding author.
| | - Philip McCall
- Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK,Department of Anaesthesia, Golden Jubilee National Hospital, Clydebank, UK
| | - Alex Arthur
- Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK
| | - Kenneth Mangion
- British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Ben Shelley
- Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK,Department of Anaesthesia, Golden Jubilee National Hospital, Clydebank, UK
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16
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Abstract
PURPOSE OF REVIEW Right ventricular (RV) failure is increasingly recognized as a major cause of morbidity and mortality. When RV failure is refractory to medical therapy, escalation to right-sided mechanical circulatory support (MCS) should be considered. In this review, we begin by recapitulating the hemodynamics of RV failure, then we delve into current and future right-sided MCS devices and describe their hemodynamic profiles. RECENT FINDINGS The field of temporary right-sided MCS continues to expand, with evolving strategies and new devices actively under development. All right-sided MCS devices bypass the RV, with each bypass configuration conferring a unique hemodynamic profile. Devices that aspirate blood directly from the RV, as opposed to the RA or the IVC, have more favorable hemodynamics and more effective RV unloading. There has been a growing interest in single-access MCS devices which do not restrict patient mobility. Additionally, a first-of-its-kind percutaneous, pulsatile, right-sided MCS device (PERKAT RV) is currently undergoing investigation in humans. Prompt recognition of refractory RV failure and deployment of right-sided MCS can improve outcomes. The field of right-sided MCS is rapidly evolving, with ongoing efforts dedicated towards developing novel temporary devices that are single access, allow for patient mobility, and directly unload the RV, as well as more durable devices.
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17
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Rieth AJ, Rivinius R, Lühring T, Grün D, Keller T, Grinninger C, Schüttler D, Bara CL, Helmschrott M, Frey N, Sandhaus T, Schulze C, Kriechbaum S, Vietheer J, Sindermann J, Welp H, Lichtenberg A, Choi YH, Richter M, Tello K, Richter MJ, Hamm CW, Boeken U. Hemodynamic markers of pulmonary vasculopathy for prediction of early right heart failure and mortality after heart transplantation. J Heart Lung Transplant 2022; 42:512-521. [PMID: 36333208 DOI: 10.1016/j.healun.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/13/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Elevated pulmonary vascular resistance (PVR) is broadly accepted as an imminent risk factor for mortality after heart transplantation (HTx). However, no current HTx recipient risk score includes PVR or other hemodynamic parameters. This study examined the utility of various hemodynamic parameters for risk stratification in a contemporary HTx population. METHODS Patients from seven German HTx centers undergoing HTx between 2011 and 2015 were included retrospectively. Established risk factors and complete hemodynamic datasets before HTx were analyzed. Outcome measures were overall all-cause mortality, 12-month mortality, and right heart failure (RHF) after HTx. RESULTS The final analysis included 333 patients (28% female) with a median age of 54 (IQR 46-60) years. The median mean pulmonary artery pressure was 30 (IQR 23-38) mm Hg, transpulmonary gradient 8 (IQR 5-10) mm Hg, and PVR 2.1 (IQR 1.5-2.9) Wood units. Overall mortality was 35.7%, 12-month mortality was 23.7%, and the incidence of early RHF was 22.8%, which was significantly associated with overall mortality (log-rank HR 4.11, 95% CI 2.47-6.84; log-rank p < .0001). Pulmonary arterial elastance (Ea) was associated with overall mortality (HR 1.74, 95% CI 1.25-2.30; p < .001) independent of other non-hemodynamic risk factors. Ea values below a calculated cutoff represented a significantly reduced mortality risk (HR 0.38, 95% CI 0.19-0.76; p < .0001). PVR with the established cutoff of 3.0 WU was not significant. Ea was also significantly associated with 12-month mortality and RHF. CONCLUSIONS Ea showed a strong impact on post-transplant mortality and RHF and should become part of the routine hemodynamic evaluation in HTx candidates.
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Affiliation(s)
- Andreas J Rieth
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany.
| | - Rasmus Rivinius
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany, German Center for Cardiovascular Research (DZHK), Heidelberg/Mannheim, Germany
| | - Tom Lühring
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany
| | - Dimitri Grün
- Department of Cardiology, Justus Liebig University Giessen, Giessen, Germany
| | - Till Keller
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany; Department of Cardiology, Justus Liebig University Giessen, Giessen, Germany
| | - Carola Grinninger
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Dominik Schüttler
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Christoph L Bara
- Department of Cardiac, Thorax, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Matthias Helmschrott
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany, German Center for Cardiovascular Research (DZHK), Heidelberg/Mannheim, Germany
| | - Norbert Frey
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany, German Center for Cardiovascular Research (DZHK), Heidelberg/Mannheim, Germany
| | - Tim Sandhaus
- Department of Cardiac Surgery, University Hospital Jena, Jena, Germany
| | | | - Steffen Kriechbaum
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany
| | - Julia Vietheer
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany
| | - Jürgen Sindermann
- Department of Cardiology, Münster University Hospital, Münster, Germany; Department of Rehabilitation, Schüchtermann Clinic, Bad Rothenfelde, Germany
| | - Henryk Welp
- Department of Cardiac Surgery, Münster University Hospital, Münster, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Yeong-Hoon Choi
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Manfred Richter
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Khodr Tello
- Department of Internal Medicine, Justus Liebig University Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Manuel J Richter
- Department of Internal Medicine, Justus Liebig University Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany; Department of Pneumology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany; Department of Cardiology, Justus Liebig University Giessen, Giessen, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Düsseldorf University Hospital, Düsseldorf, Germany
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18
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Lee MH, Menezes TCF, Reisz JA, Ferreira EVM, Graham BB, Oliveira RKF. Exercise metabolomics in pulmonary arterial hypertension: Where pulmonary vascular metabolism meets exercise physiology. Front Physiol 2022; 13:963881. [PMID: 36171971 PMCID: PMC9510894 DOI: 10.3389/fphys.2022.963881] [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: 06/08/2022] [Accepted: 08/23/2022] [Indexed: 01/29/2023] Open
Abstract
Pulmonary arterial hypertension is an incurable disease marked by dysregulated metabolism, both at the cellular level in the pulmonary vasculature, and at the whole-body level characterized by impaired exercise oxygen consumption. Though both altered pulmonary vascular metabolism and abnormal exercise physiology are key markers of disease severity and pulmonary arterial remodeling, their precise interactions are relatively unknown. Herein we review normal pulmonary vascular physiology and the current understanding of pulmonary vascular cell metabolism and cardiopulmonary response to exercise in Pulmonary arterial hypertension. We additionally introduce a newly developed international collaborative effort aimed at quantifying exercise-induced changes in pulmonary vascular metabolism, which will inform about underlying pathophysiology and clinical management. We support our investigative approach by presenting preliminary data and discuss potential future applications of our research platform.
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Affiliation(s)
- Michael H. Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Thaís C. F. Menezes
- Division of Respiratory Diseases, Department of Medicine, Federal University of SP, São Paulo, Brazil
| | - Julie A. Reisz
- Department of Biochemistry and Molecular Genetics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Eloara V. M. Ferreira
- Division of Respiratory Diseases, Department of Medicine, Federal University of SP, São Paulo, Brazil
| | - Brian B. Graham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Rudolf K. F. Oliveira
- Division of Respiratory Diseases, Department of Medicine, Federal University of SP, São Paulo, Brazil,*Correspondence: Rudolf K. F. Oliveira,
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19
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Sacco A, Morici N, Oreglia JA, Tavazzi G, Villanova L, Colombo C, Garatti L, Mondino MG, Nava S, Pappalardo F. Left Ventricular Unloading in Acute on Chronic Heart Failure: From Statements to Clinical Practice. J Pers Med 2022; 12:jpm12091463. [PMID: 36143247 PMCID: PMC9502778 DOI: 10.3390/jpm12091463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/30/2022] [Accepted: 09/03/2022] [Indexed: 11/16/2022] Open
Abstract
Cardiogenic shock remains a deadly complication of acute on chronic decompensated heart failure (ADHF-CS). Despite its increasing prevalence, it is incompletely understood and therefore often misdiagnosed in the early phase. Precise diagnosis of the underlying cause of CS is fundamental for undertaking the correct therapeutic strategy. Temporary mechanical circulatory support (tMCS) is the mainstay of management: identifying and selecting optimal patients through understanding of the hemodynamics and a prompt profiling and timing, is key for success. A recent statement from the American Heart Association provided pragmatic suggestions on tMCS device selection, escalation, and weaning strategies. However, several areas of uncertainty still remain in clinical practice. Accordingly, we present an overview of the main pitfalls that can occur during patients’ management with tMCS through a clinical case. This case illustrates the strict interdependency between left ventricular unloading and right ventricular dysfunction in the case of low filling pressures. Moreover, it further illustrates the pivotal role of stepwise escalation of therapy in a patient with an ADHF-CS and its peculiarities as compared to other forms of acute heart failure.
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Affiliation(s)
- Alice Sacco
- ”De Gasperis” Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 2011 Milan, Italy
- Correspondence: ; Tel.: +39-026-444-2565; Fax: +39-026-444-2818
| | - Nuccia Morici
- IRCCS Fondazione Don Gnocchi, Dipartimento Cardio-Respiratorio, 2011 Milan, Italy
| | - Jacopo Andrea Oreglia
- ”De Gasperis” Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 2011 Milan, Italy
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia Italy, 27100 Pavia, Italy
- Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Anestesia e Rianimazione I, 27100 Pavia, Italy
| | - Luca Villanova
- ”De Gasperis” Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 2011 Milan, Italy
| | - Claudia Colombo
- ”De Gasperis” Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 2011 Milan, Italy
| | - Laura Garatti
- ”De Gasperis” Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 2011 Milan, Italy
| | | | - Stefano Nava
- ”De Gasperis” Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 2011 Milan, Italy
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, 15100 Alessandria, Italy
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20
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Granton J, Teijeiro-Paradis R. Management of the Critically Ill Patient with Pulmonary Arterial Hypertension and Right Heart Failure. Clin Chest Med 2022; 43:425-439. [PMID: 36116812 DOI: 10.1016/j.ccm.2022.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Right ventricular (RV) failure is a recognized complication of pulmonary hypertension (PH). Pregnancy and surgery represent unique challenges to the patient with PH and require input from an interprofessional team. Approach to treatment must embrace sound physiologic principles that are based on optimization of RV preload, contractility, and afterload to improve cardiac function and tissue perfusion before the onset of multiorgan dysfunction. Failure of medical therapy needs to be recognized before the onset of irreversible shock. When appropriate, eligible patients should be considered for mechanical circulatory support as a bridge to recovery or transplantation.
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Affiliation(s)
- John Granton
- University of Toronto, Pulmonary and Critical Care Medicine, University Health Network, 9-9023 MARS Building, 585 University Avenue, Toronto, Ontario M5G 2N2, Canada.
| | - Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care, University of Toronto, University Health Network, 585 University Avenue, Toronto, Ontario M5G 2N2, Canada
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21
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Tsarova K, Morgan AE, Melendres-Groves L, Ibrahim MM, Ma CL, Pan IZ, Hatton ND, Beck EM, Ferrel MN, Selzman CH, Ingram D, Alamri AK, Ratcliffe MB, Wilson BD, Ryan JJ. Imaging in Pulmonary Vascular Disease-Understanding Right Ventricle-Pulmonary Artery Coupling. Compr Physiol 2022; 12:3705-3730. [PMID: 35950653 DOI: 10.1002/cphy.c210017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The right ventricle (RV) and pulmonary arterial (PA) tree are inextricably linked, continually transferring energy back and forth in a process known as RV-PA coupling. Healthy organisms maintain this relationship in optimal balance by modulating RV contractility, pulmonary vascular resistance, and compliance to sustain RV-PA coupling through life's many physiologic challenges. Early in states of adaptation to cardiovascular disease-for example, in diastolic heart failure-RV-PA coupling is maintained via a multitude of cellular and mechanical transformations. However, with disease progression, these compensatory mechanisms fail and become maladaptive, leading to the often-fatal state of "uncoupling." Noninvasive imaging modalities, including echocardiography, magnetic resonance imaging, and computed tomography, allow us deeper insight into the state of coupling for an individual patient, providing for prognostication and potential intervention before uncoupling occurs. In this review, we discuss the physiologic foundations of RV-PA coupling, elaborate on the imaging techniques to qualify and quantify it, and correlate these fundamental principles with clinical scenarios in health and disease. © 2022 American Physiological Society. Compr Physiol 12: 1-26, 2022.
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Affiliation(s)
- Katsiaryna Tsarova
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ashley E Morgan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Lana Melendres-Groves
- Division of Pulmonary and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Majd M Ibrahim
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Christy L Ma
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Irene Z Pan
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
| | - Nathan D Hatton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Emily M Beck
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Meganne N Ferrel
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Dominique Ingram
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ayedh K Alamri
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | | | - Brent D Wilson
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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22
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Hariri E, Kakouros N, Bunsick DA, Russell SD, Mudd JO, Laws K, Lake MW, Rade JJ. Non-platelet thromboxane generation is associated with impaired cardiovascular performance and mortality in heart failure. Am J Physiol Heart Circ Physiol 2022; 323:H248-H255. [PMID: 35714178 DOI: 10.1152/ajpheart.00212.2022] [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] [Indexed: 11/22/2022]
Abstract
BACKGROUND Non-platelet thromboxane generation, stimulated largely by oxidative stress, is a novel mortality risk factor in individuals with coronary artery disease. Though inversely associated with left ventricular ejection fraction (LVEF), a potential role in the pathobiology of heart failure (HF) remains poorly defined. METHODS Non-platelet thromboxane generation and oxidative stress were assessed by measuring urine thromboxane B2 metabolites (TXB2-M) and 8-isoPGF2α by ELISA in 105 subjects taking aspirin undergoing right heart catheterization for evaluation of HF, valve disease or after transplantation. Multivariable logistic regression and survival analyses were used to define associations of TXB2-M to invasive measures of cardiovascular performance and 4-year clinical outcome. RESULTS TXB2-M was elevated (>1500 pg/mg creatinine) in 46% of subjects and correlated with HF severity by NYHA functional class and brain natriuretic peptide level, modestly with LVEF, but not with HF etiology. There was no association of oxidative stress to HF type or etiology but a trend with NYHA functional class. Multiple invasive hemodynamic parameters independently associated with TXB2-M after adjustment for oxidative stress, age, sex and race with pulmonary effective arterial elastance (Ea (pulmonary)), reflective of right ventricular afterload, being the most robust on hierarchical analysis. Similar to Ea (pulmonary), elevated urinary TXB2-M associated with increased risk of death (adjusted HR 2.15, P=0.037) and combination of death, transplant, or mechanical support initiation (adjusted HR 2.0, P=0.042). CONCLUSIONS Non-platelet TXA2 thromboxane generation independently associated with HF severity reflected by invasive measures of cardiovascular performance, particularly right ventricular afterload, and independently predicted long-term mortal.
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Affiliation(s)
- Essa Hariri
- University of Massachusetts Medical School, Worcester, MA, United States.,Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Nikolaos Kakouros
- University of Massachusetts Medical School, Worcester, MA, United States
| | - David A Bunsick
- University of Massachusetts Medical School, Worcester, MA, United States
| | | | - James O Mudd
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Katherine Laws
- University of Massachusetts Medical School, Worcester, MA, United States
| | | | - Jeffrey J Rade
- University of Massachusetts Medical School, Worcester, MA, United States.,Cleveland Clinic Foundation, Cleveland, OH, United States
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23
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Wang TS, Cevasco M, Birati EY, Mazurek JA. Predicting, Recognizing, and Treating Right Heart Failure in Patients Undergoing Durable LVAD Therapy. J Clin Med 2022; 11:jcm11112984. [PMID: 35683372 PMCID: PMC9181012 DOI: 10.3390/jcm11112984] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 12/04/2022] Open
Abstract
Despite advancing technology, right heart failure after left ventricular assist device implantation remains a significant source of morbidity and mortality. With the UNOS allocation policy change, a larger proportion of patients proceeding to LVAD are destination therapy and consist of an overall sicker population. Thus, a comprehensive understanding of right heart failure is critical for ensuring the ongoing success of durable LVADs. The purpose of this review is to describe the effect of LVAD implantation on right heart function, review the diagnostic and predictive criteria related to right heart failure, and discuss the current evidence for management and treatment of post-LVAD right heart failure.
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Affiliation(s)
- Teresa S. Wang
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
- Correspondence: ; Tel.: +1-267-624-7276
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Edo Y. Birati
- Division of Cardiovascular Medicine, Padeh-Poriya Medical Center, Bar-Ilan University, Ramat Gan 5290002, Israel;
| | - Jeremy A. Mazurek
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
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24
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Kreit J. Respiratory-Cardiovascular Interactions During Mechanical Ventilation: Physiology and Clinical Implications. Compr Physiol 2022; 12:3425-3448. [PMID: 35578946 DOI: 10.1002/cphy.c210003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Positive-pressure inspiration and positive end-expiratory pressure (PEEP) increase pleural, alveolar, lung transmural, and intra-abdominal pressure, which decrease right and left ventricular (RV; LV) preload and LV afterload and increase RV afterload. The magnitude and clinical significance of the resulting changes in ventricular function are determined by the delivered tidal volume, the total level of PEEP, the compliance of the lungs and chest wall, intravascular volume, baseline RV and LV function, and intra-abdominal pressure. In mechanically ventilated patients, the most important, adverse consequences of respiratory-cardiovascular interactions are a PEEP-induced reduction in cardiac output, systemic oxygen delivery, and blood pressure; RV dysfunction in patients with ARDS; and acute hemodynamic collapse in patients with pulmonary hypertension. On the other hand, the hemodynamic changes produced by respiratory-cardiovascular interactions can be beneficial when used to assess volume responsiveness in hypotensive patients and by reducing dyspnea and improving hypoxemia in patients with cardiogenic pulmonary edema. Thus, a thorough understanding of the physiological principles underlying respiratory-cardiovascular interactions is essential if critical care practitioners are to anticipate, recognize, manage, and utilize their hemodynamic effects. © 2022 American Physiological Society. Compr Physiol 12:1-24, 2022.
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Affiliation(s)
- John Kreit
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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25
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Rieth AJ, Grün D, Zarogiannis G, Kriechbaum SD, Wolter S, Richter MJ, Tello K, Krüger U, Mitrovic V, Rosenkranz S, Hamm CW, Keller T. Prognostic Power of Pulmonary Arterial Compliance Is Boosted by a Hemodynamic Unloading Test With Glyceryl Trinitrate in Heart Failure Patients With Post-capillary Pulmonary Hypertension. Front Cardiovasc Med 2022; 9:838898. [PMID: 35433862 PMCID: PMC9008270 DOI: 10.3389/fcvm.2022.838898] [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] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background Pulmonary hypertension (PH) is an established risk factor in patients with heart failure (HF). However, right heart catheterisation (RHC) and vasoreactivity testing (VRT) are not routinely recommended in these patients. Methods The primary objective of the present study was to explore the impact of VRT using sublingual glyceryl trinitrate (GTN) on transplant/ventricular assist device-free survival in HF patients with post-capillary PH. RHC parameters were correlated retrospectively with the primary outcome. Results The cohort comprised 154 HF patients with post-capillary PH undergoing RHC with GTN-VRT at a tertiary heart failure centre. Multiple parameters were associated with survival. After adjustment for established prognosis-relevant clinical variables from the MAGGIC Score, variables with the most relevant odds ratios (OR) obtained after GTN-VRT were: calculated effective pulmonary arterial (PA) elastance (adjusted OR 2.26, 95%CI 1.30-3.92; p = 0.004), PA compliance (PAC-GTN; adjusted OR 0.45, 95%CI 0.25-0.80; p = 0.006), and total pulmonary resistance (adjusted OR 2.29, 95%CI 1.34-3.93; p = 0.003). Forest plot analysis including these three variables as well as PAC at baseline, delta PAC, and the presence of combined post- and pre-capillary PH revealed prognostic superiority of PAC-GTN, which was confirmed by Kaplan-Meier analysis. Conclusions In our cohort of symptomatic HF patients with post-capillary PH, improved PAC after administration of GTN was associated with survival independent of established hemodynamic and clinical risk factors. VRT using GTN may be better described as unloading test due to GTN's complex effects on the circulation. This could be used for advanced prognostication and should be investigated in further studies.
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Affiliation(s)
- Andreas J. Rieth
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Frankfurt am Main, Germany
| | - Dimitri Grün
- Department of Internal Medicine I, Cardiology, Justus-Liebig-University Giessen, Giessen, Germany
| | | | - Steffen D. Kriechbaum
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Frankfurt am Main, Germany
| | - Sebastian Wolter
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Frankfurt am Main, Germany
| | - Manuel J. Richter
- Department of Pneumology, Kerckhoff-Klinik, Bad Nauheim, Germany
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus Liebig University Giessen, Giessen, Germany
| | - Khodr Tello
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus Liebig University Giessen, Giessen, Germany
| | - Ulrich Krüger
- Department of Cardiology, Evangelisches Klinikum Niederrhein, Duisburg, Germany
| | - Veselin Mitrovic
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Frankfurt am Main, Germany
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine, Department of Cardiology, Heart Center at the University of Cologne and Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
| | - Christian W. Hamm
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Frankfurt am Main, Germany
- Department of Internal Medicine I, Cardiology, Justus-Liebig-University Giessen, Giessen, Germany
| | - Till Keller
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Frankfurt am Main, Germany
- Department of Internal Medicine I, Cardiology, Justus-Liebig-University Giessen, Giessen, Germany
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26
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Quintero-Martinez JA, Wysokinski WE, Cordova-Madera SN, Mogollon RJ, Garcia-Arango M, Vlazny DT, Houghton DE, Casanegra AI, Villarraga HR. Pulmonary artery capacitance and pulmonary vascular resistance as prognostic indicators in acute pulmonary embolism. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac007. [PMID: 35919120 PMCID: PMC9242029 DOI: 10.1093/ehjopen/oeac007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/28/2021] [Accepted: 02/21/2022] [Indexed: 12/13/2022]
Abstract
Abstract
Aims
The non-invasive calculation of right ventricular (RV) haemodynamics as pulmonary artery (PA) capacitance (PAC) and pulmonary vascular resistance (PVR) have proved to be feasible, easy to perform, and of high prognostic value. We, therefore, evaluated whether baseline PAC and PVR could predict clinical outcomes for patients with acute pulmonary embolism (PE).
Methods and results
We prospectively followed 373 patients [mean (standard deviation) age, 64.1 (14.9) years; 58.4% were men, and 27.9% had cancer] who had acute PE and transthoracic echocardiography within 1 day of diagnosis from 1 March 2013 through 30 June 2020. Pulmonary artery capacitance was calculated as left ventricular stroke volume/(PA systolic pressure − PA diastolic pressure). Pulmonary vascular resistance was calculated as (tricuspid regurgitant velocity/RV outflow tract velocity time integral) × 10 + 0.16. These two variables were calculated retrospectively from the values obtained with transthoracic echocardiography. Pulmonary artery capacitance was acquired in 99 (27%) patients and PVR in 65 (17%) patients. Univariable and bivariable logistic regression analyses, and receiver operating characteristic curves were used to evaluate the ability of these haemodynamic measurements to predict mortality up to 6 months. After using bivariable models to adjust individually for age, cancer, and pulmonary hypertension. Pulmonary vascular resistance was associated with all-cause mortality at 3 months [area under the curve (AUC) 0.75, 95% confidence interval (CI) 0.61–0.86; P = 0.01], and 6 months (AUC 0.81; 95% CI 0.69–0.91; P≤ 0.03). Pulmonary artery capacitance was associated with all-cause mortality at 30 days (AUC 0.95; 95% CI 0.82–0.99; P < 0.001) and 3 months (AUC 0.84; 95% CI 0.65–0.99; P = 0.003).
Conclusion
Non-invasive measurement of RV haemodynamics could provide prognostic information of patients with acute PE. Pulmonary artery capacitance and PVR are potentially important predictors of all-cause mortality in these patients and should be explored in future studies.
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Affiliation(s)
- Juan A Quintero-Martinez
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
| | - Waldemar E Wysokinski
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
| | - Sandra N Cordova-Madera
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
| | - Renzo J Mogollon
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
| | - Mariana Garcia-Arango
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
| | - Danielle T Vlazny
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
| | - Damon E Houghton
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
| | - Ana I Casanegra
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
| | - Hector R Villarraga
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine , Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic , 200 First St SW, Rochester, MN 55905, USA
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27
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Pulmonary vascular resistance and compliance in pulmonary blood flow alterations in children with congenital heart disease. Heart Vessels 2022; 37:1283-1289. [PMID: 35001144 DOI: 10.1007/s00380-021-02009-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 12/03/2021] [Indexed: 01/29/2023]
Abstract
There is a unique hyperbolic relationship between pulmonary vascular resistance (Rp) and compliance (Cp); however, the characteristics of this coupling curve in pulmonary blood flow alterations remains unknown in children with congenital heart disease. We aimed to explore the Rp-Cp coupling and resistant-compliance (RC) time among them. We retrospectively reviewed catheterization data and calculated Rp and Cp in 217 subjects with ventricular septal defect. Median age and weight at catheterization were 2.8 (1.7-4.4) months and 4.3 (3.7-5.3) kg, respectively. Pulmonary hemodynamic parameters were as follows: mean pulmonary arterial pressure: 36 (28-43) mmHg; the amount of pulmonary blood flow (Qp): 14.2 (11.6-17.6) L/min/m2; Rp: 1.95 (1.38-2.59) Wood unit m2; Cp: 2.98 (2.42-3.88) mmHg/mL/m2; and RC time: 0.35 (0.30-0.40) s. RC time remained unchanged according to alterations in Qp (P = 0.206); however, the relationship between logarithm transformations of Rp and Cp showed more steeper according to an increase in Qp. The pulmonary circulation depends upon Cp rather than Rp according to the degree of Qp despite the constancy in RC time. We should take both Rp and Cp into consideration when evaluating the pulmonary circulation among children with congenital heart disease.
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Orkild BA, Zenger B, Iyer K, Rupp LC, Ibrahim MM, Khashani AG, Perez MD, Foote MD, Bergquist JA, Morris AK, Kim JJ, Steinberg BA, Selzman C, Ratcliffe MB, MacLeod RS, Elhabian S, Morgan AE. All Roads Lead to Rome: Diverse Etiologies of Tricuspid Regurgitation Create a Predictable Constellation of Right Ventricular Shape Changes. Front Physiol 2022; 13:908552. [PMID: 35860653 PMCID: PMC9291517 DOI: 10.3389/fphys.2022.908552] [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] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/16/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: Myriad disorders cause right ventricular (RV) dilation and lead to tricuspid regurgitation (TR). Because the thin-walled, flexible RV is mechanically coupled to the pulmonary circulation and the left ventricular septum, it distorts with any disturbance in the cardiopulmonary system. TR, therefore, can result from pulmonary hypertension, left heart failure, or intrinsic RV dysfunction; but once it occurs, TR initiates a cycle of worsening RV volume overload, potentially progressing to right heart failure. Characteristic three-dimensional RV shape-changes from this process, and changes particular to individual TR causes, have not been defined in detail. Methods: Cardiac MRI was obtained in 6 healthy volunteers, 41 patients with ≥ moderate TR, and 31 control patients with cardiac disease without TR. The mean shape of each group was constructed using a three-dimensional statistical shape model via the particle-based shape modeling approach. Changes in shape were examined across pulmonary hypertension and congestive heart failure subgroups using principal component analysis (PCA). A logistic regression approach based on these PCA modes identified patients with TR using RV shape alone. Results: Mean RV shape in patients with TR exhibited free wall bulging, narrowing of the base, and blunting of the RV apex compared to controls (p < 0.05). Using four primary PCA modes, a logistic regression algorithm identified patients with TR correctly with 82% recall and 87% precision. In patients with pulmonary hypertension without TR, RV shape was narrower and more streamlined than in healthy volunteers. However, in RVs with TR and pulmonary hypertension, overall RV shape continued to demonstrate the free wall bulging characteristic of TR. In the subgroup of patients with congestive heart failure without TR, this intermediate state of RV muscular hypertrophy was not present. Conclusion: The multiple causes of TR examined in this study changed RV shape in similar ways. Logistic regression classification based on these shape changes reliably identified patients with TR regardless of etiology. Furthermore, pulmonary hypertension without TR had unique shape features, described here as the "well compensated" RV. These results suggest shape modeling as a promising tool for defining severity of RV disease and risk of decompensation, particularly in patients with pulmonary hypertension.
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Affiliation(s)
- Benjamin A. Orkild
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, United States
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States
| | - Brian Zenger
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, United States
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States
| | - Krithika Iyer
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, United States
- School of Computing, University of Utah, Salt Lake City, UT, United States
| | - Lindsay C. Rupp
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, United States
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States
| | - Majd M Ibrahim
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, United States
| | - Atefeh G. Khashani
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, United States
| | - Maura D. Perez
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, United States
| | - Markus D. Foote
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, United States
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States
| | - Jake A. Bergquist
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, United States
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States
| | - Alan K. Morris
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, United States
| | - Jiwon J. Kim
- Weill-Cornell Medical College, Division of Cardiology, New York, NY, United States
| | - Benjamin A. Steinberg
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, United States
| | - Craig Selzman
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, United States
| | - Mark B. Ratcliffe
- Department of Surgery, The San Francisco VA Medical Center, University of California, San Francisco, San Francisco, CA, United States
| | - Rob S. MacLeod
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, United States
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States
| | - Shireen Elhabian
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, United States
- School of Computing, University of Utah, Salt Lake City, UT, United States
- *Correspondence: Ashley E. Morgan, ; Shireen Elhabian,
| | - Ashley E. Morgan
- St. Luke’s Medical Center Cardiothoracic and Vascular Surgery, Boise, ID, United States
- *Correspondence: Ashley E. Morgan, ; Shireen Elhabian,
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Nakagawa A, Yasumura Y, Yoshida C, Okumura T, Tateishi J, Yoshida J, Abe H, Tamaki S, Yano M, Hayashi T, Nakagawa Y, Yamada T, Dohi T, Nakatani D, Hikoso S, Sakata Y. Prognostic Importance of Pulmonary Arterial Capacitance in Acute Decompensated Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2021; 10:e023043. [PMID: 34612057 PMCID: PMC8751883 DOI: 10.1161/jaha.121.023043] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Although the prognostic importance of pulmonary arterial capacitance (PAC; stroke volume/pulmonary arterial pulse pressure) has been elucidated in heart failure with reduced ejection fraction, whether its significance in patients suffering from heart failure with preserved ejection fraction is not known. We aimed to examine the association of PAC with outcomes in inpatients with heart failure with preserved ejection fraction. Methods and Results We prospectively studied 705 patients (median age, 83 years; 55% women) registered in PURSUIT‐HFpEF (Prospective Multicenter Observational Study of Patients With Heart Failure With Preserved Ejection Fraction). We investigated the association of echocardiographic PAC at discharge with the primary end point of all‐cause death or heart failure rehospitalization with a mean follow‐up of 384 days. We further tested the acceptability of the prognostic significance of PAC in a subgroup of patients (167/705 patients; median age, 81 years; 53% women) in whom PAC was assessed by right heart catheterization. The median echocardiographic PAC was 2.52 mL/mm Hg, with a quartile range of 1.78 to 3.32 mL/mm Hg. Univariable and multivariable Cox regression testing revealed that echocardiographic PAC was associated with the primary end point (unadjusted hazard ratio, 0.82; 95% CI, 0.72–0.92; P=0.001; adjusted hazard ratio, 0.86; 95% CI, 0.74–0.99; P=0.035, respectively). Univariable Cox regression testing revealed that PAC assessed by right heart catheterization (median calculated PAC, 2.82 mL/mm Hg) was also associated with the primary end point (unadjusted HR, 0.70; 95% CI, 0.52–0.91; P=0.005). Conclusions A prospective cohort study revealed that impaired PAC diagnosed with both echocardiography and right heart catheterization was associated with adverse outcomes in inpatients with heart failure with preserved ejection fraction. Registration URL: https://upload.umin.ac.jp/cgi‐open‐bin/ctr_e/ctr_view.cgi?recptno=R000024414. Unique identifier: UMIN000021831.
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Affiliation(s)
- Akito Nakagawa
- Division of Cardiovascular Medicine Amagasaki-Chuo Hospital Amagasaki Japan.,Department of Medical Informatics Osaka University Graduate School of Medicine Suita Japan
| | - Yoshio Yasumura
- Division of Cardiovascular Medicine Amagasaki-Chuo Hospital Amagasaki Japan
| | - Chikako Yoshida
- Division of Cardiovascular Medicine Amagasaki-Chuo Hospital Amagasaki Japan
| | - Takahiro Okumura
- Division of Cardiovascular Medicine Amagasaki-Chuo Hospital Amagasaki Japan
| | - Jun Tateishi
- Division of Cardiovascular Medicine Amagasaki-Chuo Hospital Amagasaki Japan
| | - Junichi Yoshida
- Division of Cardiovascular Medicine Amagasaki-Chuo Hospital Amagasaki Japan
| | - Haruhiko Abe
- Cardiovascular Division National Hospital Organization Osaka National Hospital Osaka Japan
| | - Shunsuke Tamaki
- Division of Cardiology Osaka General Medical Center Osaka Japan
| | | | | | | | - Takahisa Yamada
- Division of Cardiology Osaka General Medical Center Osaka Japan
| | - Tomoharu Dohi
- Department of Cardiovascular Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Daisaku Nakatani
- Department of Cardiovascular Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine Osaka University Graduate School of Medicine Suita Japan
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30
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Marino PN. Left atrial conduit function: A short review. Physiol Rep 2021; 9:e15053. [PMID: 34605214 PMCID: PMC8488566 DOI: 10.14814/phy2.15053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 08/06/2021] [Accepted: 08/29/2021] [Indexed: 11/24/2022] Open
Abstract
Three-dimensional echocardiography can elucidate the phasic functions of the left atrium if a simultaneous acquisition of a pyramidal full-volume dataset, as gathered from the apical window and containing the entire left atrial and left ventricular cardiac sections, is obtained. Hence, conduit can be quantified as the integral of net, diastolic, instantaneous difference between synchronized atrial and ventricular volume curves, beginning at minimum ventricular cavity volume and ending just before atrial contraction. Increased conduit can reflect increased downstream suction, as conduit would track the apex-to-base intracavitary pressure gradient existing, in early diastole, within the single chamber formed by the atrium and the ventricle, when the mitral valve is open. Such a gradient increases in response to adrenergic stimulation or during exercise and mediates an increment in passive flow during early diastole, with the ventricle being filled from the atrial reservoir and, simultaneously, from blood drawn from the pulmonary veins. In this context conduit, and even more conduit flow rate, expressed in ml/sec, can be viewed as an indirect marker of left ventricular relaxation. It is well known, however, that a large amount of conduit (in relative terms) is also supposed to contribute to LV stroke volume in conditions of increased resistance to LV filling, when diastolic function significantly worsens. Stiffening of the atrio-ventricular complex implies increments in LA pressure more pronounced in late systole, causing markedly elevated "v" waves, independently of the presence of mitral insufficiency. The combination of increased atrio-ventricular stiffness and conduit flow is associated with an elevation of the right ventricular pulsatile relative to resistive load that negatively impacts on exercise capacity and survival in these patients. Atrial conduit is an "intriguing" parameter that conveys a noninvasive picture of the complex atrioventricular coupling condition in diastole and its backward effects on the right side of the heart and the pulmonary circulation. Given the easiness associated with its correctly performed quantification in the imaging laboratory, I am sure that conduit will survive the competitive access to the list of valuable parameters capable of deciphering, although not necessarily simplifying, the complex diastolic scenario in health and disease.
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Affiliation(s)
- Paolo N. Marino
- School of MedicineUniversità del Piemonte OrientaleNovaraItaly
- Istituto IperbaricoVillafranca (Verona)Italy
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31
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Petit T, Claessen G, Claeys M, La Gerche A, Claus P, Ghysels S, Delcroix M, Ciarka A, Droogne W, Van Cleemput J, Willems R, Voigt JU, Bogaert J, Janssens S. Right ventricular and cyclic guanosine monophosphate signalling abnormalities in stages B and C of heart failure with preserved ejection fraction. ESC Heart Fail 2021; 8:4661-4673. [PMID: 34477327 PMCID: PMC8712894 DOI: 10.1002/ehf2.13514] [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] [Received: 12/21/2020] [Revised: 05/20/2021] [Accepted: 07/05/2021] [Indexed: 01/05/2023] Open
Abstract
Aims Identifying early right ventricular (RV) dysfunction and impaired vasodilator reserve is challenging in heart failure with preserved ejection fraction (HFpEF). We hypothesized that cardiac magnetic resonance (CMR)‐based exercise imaging and serial cyclic guanosine monophosphate (cGMP) measurements can identify dynamic RV‐arterial uncoupling and responsiveness to pulmonary vasodilators at early stages of the HFpEF syndrome. Methods and results Patients with HFpEF (n = 16), impaired left ventricular relaxation due to concentric remodelling (LVCR, n = 7), and healthy controls (n = 8) underwent CMR at rest and during supine bicycle exercise with simultaneous measurements of central haemodynamics and circulating cGMP levels, before and after oral administration of 50 mg sildenafil. At rest, mean pulmonary artery pressures (mPAP) were higher in HFpEF, compared with LVCR and controls (27 ± 2, 18 ± 1, and 11 ± 1, respectively; P = 0.01), whereas biventricular volumes, heart rate, and stroke volume were similar. During exercise, LVCR and HFpEF had a greater increase in the ratio of mPAP over cardiac output than controls (5.50 ± 0.77 and 6.34 ± 0.86 vs. 2.24 ± 0.55 in controls, P = 0.005). The ratio of peak exercise to rest RV end‐systolic pressure‐volume, a surrogate of RV contractility, was significantly reduced in LVCR and HFpEF (2.32 ± 0.17 and 1.56 ± 0.08 vs. 3.49 ± 0.35 in controls, P < 0.001) and correlated with peak exercise VO2 (R2 = 0.648, P < 0.001). cGMP levels increased with exercise across the HFpEF spectrum (P < 0.05 vs. baseline), except when postcapillary pulmonary hypertension was present at rest (P = 0.73 vs. baseline). A single sildenafil administration failed to increase circulating cGMP levels and did not improve RV performance. Conclusion Exercise CMR identifies impaired RV‐arterial coupling at an early stage of HFpEF. Circulating cGMP levels phenocopy the haemodynamic spectrum in HFpEF but fail to increase after phosphodiesterase type 5 inhibition, endorsing the need for alternative interventions to increase cGMP signalling in HFpEF.
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Affiliation(s)
- Thibault Petit
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
| | - Guido Claessen
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
| | - Mathias Claeys
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
| | - Andre La Gerche
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Piet Claus
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
| | - Stefan Ghysels
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Marion Delcroix
- Department of Chronic Diseaes and Metabolism, KU Leuven, Leuven, Belgium
| | - Agnieszka Ciarka
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Walter Droogne
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
| | - Johan Van Cleemput
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
| | - Rik Willems
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
| | - Jens-Uwe Voigt
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
| | - Jan Bogaert
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, Leuven, B-3000, Belgium
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Gelzinis TA. Pulmonary Hypertension in 2021: Part I-Definition, Classification, Pathophysiology, and Presentation. J Cardiothorac Vasc Anesth 2021; 36:1552-1564. [PMID: 34344595 DOI: 10.1053/j.jvca.2021.06.036] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/26/2021] [Accepted: 06/30/2021] [Indexed: 11/11/2022]
Abstract
The World Symposium on Pulmonary Hypertension (WSPH) was organized by the World Health Organization in 1973 in response to an increase in pulmonary arterial hypertension in Europe caused by aminorex, an appetite suppressant. The mandate of this meeting was to review the latest clinical and scientific research and to formulate recommendations to improve the diagnosis and management of pulmonary hypertension (PH).1 Since 1998, the WSPH has met every five years and in 2018, the sixth annual WSPH revised the hemodynamic definition of PH. This two-part series will review the updated definition, classification, pathophysiology, presentation, diagnosis, management, and perioperative management of patients with PH. In the first part of this series, the definition, classification, pathophysiology, and presentation will be reviewed.
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Changes in the Pulmonary Artery Wave Reflection in Dogs with Experimentally-Induced Acute Pulmonary Embolism and the Effect of Vasodilator. Animals (Basel) 2021; 11:ani11071977. [PMID: 34359104 PMCID: PMC8300366 DOI: 10.3390/ani11071977] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 06/23/2021] [Accepted: 06/28/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Pulmonary hypertension (PH) remains a fatal disease, despite the advances in disease-specific therapies. This may be because the assessment of pulmonary hemodynamics in PH has not been established. Recently, several studies have reported that the pulmonary arterial wave reflection (PAWR) might influence the right ventricular afterload and could provide additional information regarding the severity and progression of PH. However, the pathophysiology of PAWR has some unclear points particularly in the case of acute pulmonary embolism (APE). The objective of this study was to investigate, for the first time, the characteristics of PAWR in a dog model of APE using dual-tipped sensor wire. From the result of the present study, after dogs developed PH by injections of dextran microsphere, PAWR was increased significantly along with the pulmonary vascular resistance (PVR) and reduced after vasodilator administration. In addition, PAWR was significantly correlated with PVR and right ventricular fractional area of change (FAC). These results indicating that PAWR may be useful as a new evaluation method in PH and may detect changes related to right ventricular afterload earlier than pulmonary artery pressure (PAP). Abstract Pulmonary hypertension (PH) is a complex syndrome that has been frequently diagnosed in dogs and humans and can be detected by Doppler echocardiography and invasive catheterization. Recently, PAWR attracts much attention as a noninvasive approach for the early detection of PH. The present study aims to investigate the PAWR changes in acute pulmonary embolism (APE) and highlight the response of PAWR variables to vasodilator therapy in dogs. For this purpose, anesthesia and catheterization were performed in 6 Beagle dogs. After that, APE was experimentally conducted by Dextran microsphere administration, followed by vasodilator (Nitroprusside; 1μg/kg/min/IV) administration. The hemodynamics, echocardiography, PVR and PAWR variables were evaluated at the baseline, after APE and after administration of nitroprusside. The result showed a significant increase in PVR, PAP, tricuspid regurgitation (TR) as well as PAWR variables following APE induction compared with the baseline (p < 0.05). Vasodilation caused by administration of nitroprusside reduced the mean atrial pressure, PVR and PAWR parameters. There were a significant correlation and linear regression between PAWR indices and PVR as well as right ventricular function parameters. In conclusion, PAWR is not only correlated with PVR but also the right ventricular function parameter, which indicates that PAWR may be useful as a new evaluation method in PH, considering that PAWR can assess both right ventricular afterload and right ventricular function.
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Exercise hemodynamics in heart failure patients with preserved and mid-range ejection fraction: key role of the right heart. Clin Res Cardiol 2021; 111:393-405. [PMID: 34110459 DOI: 10.1007/s00392-021-01884-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 05/27/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE We sought to explore whether classification of patients with heart failure and mid-range (HFmrEF) or preserved ejection fraction (HFpEF) according to their left ventricular ejection fraction (LVEF) identifies differences in their exercise hemodynamic profile, and whether classification according to an index of right ventricular (RV) function improves differentiation. BACKGROUND Patients with HFmrEF and HFpEF have hemodynamic compromise on exertion. The classification according to LVEF implies a key role of the left ventricle. However, RV involvement in exercise limitation is increasingly recognized. The tricuspid annular plane systolic excursion/systolic pulmonary arterial pressure (TAPSE/PASP) ratio is an index of RV and pulmonary vascular function. Whether exercise hemodynamics differ more between HFmrEF and HFpEF than between TAPSE/PASP tertiles is unknown. METHODS We analyzed 166 patients with HFpEF (LVEF ≥ 50%) or HFmrEF (LVEF 40-49%) who underwent basic diagnostics (laboratory testing, echocardiography at rest, and cardiopulmonary exercise testing [CPET]) and exercise with right heart catheterization. Hemodynamics were compared according to echocardiographic left ventricular or RV function. RESULTS Exercise hemodynamics (e.g. pulmonary arterial wedge pressure/cardiac output [CO] slope, CO increase during exercise, and maximum total pulmonary resistance) showed no difference between HFpEF and HFmrEF, but significantly differed across TAPSE/PASP tertiles and were associated with CPET results. N-terminal pro-brain natriuretic peptide concentration also differed significantly across TAPSE/PASP tertiles but not between HFpEF and HFmrEF. CONCLUSION In patients with HFpEF or HFmrEF, TAPSE/PASP emerged as a more appropriate stratification parameter than LVEF to predict clinically relevant impairment of exercise hemodynamics. Stratification of exercise hemodynamics in patients with HFpEF or HFmrEF according to LVEF or TAPSE/PASP, showing significant distinctions only with the RV-based strategy. All data are shown as median [upper limit of interquartile range] and were calculated using the independent-samples Mann-Whitney U test or Kruskal-Wallis test. PVR pulmonary vascular resistance; max maximum level during exercise.
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Zanaboni J, Panizza A, Marino PN. Left atrial conduit function modulates right ventricular afterload, exercise capacity and survival in heart failure patients. J Cardiovasc Med (Hagerstown) 2021; 22:396-404. [PMID: 33731560 DOI: 10.2459/jcm.0000000000001171] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AIMS To assess if left atrial phasic function characteristics modulate functional capacity/survival by impacting on the pulsatile component of right ventricular (RV) afterload, as represented by pulmonary arterial compliance (PAC). MATERIALS AND METHODS Sixty heart failure patients (67 ± 11 years, ejection fraction 39 ± 11%, range 20--62%) underwent 6 min walk test (6MWT) and 3D transthoracic echocardiography. Left atrial conduit was computed off-line, gathering simultaneous real-time 3D multibeats (six cycles) left atrial and left ventricular (LV) volume curves, with conduit (time) = [LV (time) - LV minimum volume] - [left atrial maximum volume - left atrial (time)], expressed as % LV stroke volume. Atrial stiffness (Kla) was computed using noninvasively assessed wedge pressure divided by left atrial reservoir (maximum - minimum) volume. PAC was obtained as ratio between RV stroke volume, obtained as pulsed Doppler RV outflow tract envelope∗cross-sectional area, and pulmonary pulse pressure, obtained by transforming tricuspid regurgitant velocity in millimetres of mercury and considering diastolic pulmonary as a fixed fraction of systolic pressure. RESULTS Conduit averaged 34 ± 12%, PAC 3.1 ± 1.1 ml/mmHg, 6MWT 404 ± 154 m. Conduit was independent of LV volumes and ejection fraction, showing a direct dependence on noninvasive Kla (r = 0.56; P < 0.001). Dividing patients into tertiles according to 6MWT and to PAC, the largest conduit fraction was associated with the lowest functional capacity (P < 0.001) and most deranged PAC (P < 0.001), respectively, suggesting outmost RV haemodynamic burden. Tertiles of conduit predicted survival (P = 0.01). CONCLUSION Conduit depends on noninvasively assessed Kla and appears to be increased in heart failure patients with lowest capacity and worst survival, likely as RV pulsatile afterload, as reflected by PAC, is highest in these individuals.
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Affiliation(s)
- Jacopo Zanaboni
- Department of Translational Medicine, Università del Piemonte Orientale
| | - Alice Panizza
- Cardiology Division, Azienda Ospedaliera Universitaria 'Maggiore della Carità', Novara, Italy
| | - Paolo N Marino
- Department of Translational Medicine, Università del Piemonte Orientale
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Wright SP, Cheyne WS, Gelinas JC, Harper MI, Sasso JP, Eves ND. Systolic reserve maintains left ventricular-vascular coupling when challenged by adverse breathing mechanics and hypertension in healthy adults. J Appl Physiol (1985) 2021; 130:1171-1182. [PMID: 33571052 DOI: 10.1152/japplphysiol.00833.2020] [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: 11/22/2022] Open
Abstract
Augmented negative intrathoracic pressures (nITP) and dynamic hyperinflation (DH) are adverse breathing mechanics (ABM) associated with chronic obstructive pulmonary disease (COPD) that attenuate left ventricular (LV) preload and augment afterload. In COPD, hypertension (elevated systemic arterial load) commonly adds additional afterload to the LV. Combined ABM and hypertension may profoundly challenge ventricular-vascular coupling and attenuate stroke volume (SV), particularly if LV systolic reserve is limited. However, even in the healthy heart, the combined impact of ABM and systemic arterial loading on LV function and ventricular-vascular coupling has not been fully elucidated. Healthy volunteers (10 M/9 F, 24 ± 3 yr old) were challenged with mild (-10 cmH2O nITP and 25% DH) and severe (-20 cmH2O nITP and 100% DH) ABM, without and with postexercise ischemia (PEI) at each severity. LV SV, chamber geometry, end-systolic elastance (Ees), arterial elastance (Ea), and ventricular-vascular coupling (Ees:Ea) were quantified using echocardiography. Compared with resting control (58 ± 13 mL), SV decreased during mild ABM (51 ± 13 mL), mild ABM + PEI (51 ± 11 mL), severe ABM (50 ± 12 mL), and severe ABM + PEI (47 ± 11 mL) (P < 0.001); similar trends were observed for LV end-diastolic volume. The end-diastolic radius of septal curvature increased, indicating direct ventricular interaction, during severe ABM and severe ABM + PEI (P < 0.001). Compared with control (1.99 ± 0.41 mmHg/mL), Ea increased progressively with mild ABM (2.21 ± 0.47 mmHg/mL) and severe ABM (2.50 ± 0.56 mmHg/mL); at each severity, Ea was greater with superimposed PEI (P < 0.001). However, well-matched Ees increases occurred, and Ees:Ea was unchanged throughout. ABM pose a challenge to ventricular-vascular coupling that is accentuated by superimposed PEI; however, in healthy younger adults, the LV has substantial systolic reserve to maintain coupling.NEW & NOTEWORTHY In healthy younger adults, combined dynamic hyperinflation (DH) and negative intrathoracic pressures (nITP) attenuate left ventricular filling, but through different mechanisms at different severities. DH and nITP contribute to increased left ventricular afterload through mechanical effects in addition to presumed reflexive regulation, which can be further increased by elevated arterial loading. However, within this demographic, the left ventricle has substantial reserve to increase systolic performance, which matches contractility to afterload to preserve stroke volume.
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Affiliation(s)
- S P Wright
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - W S Cheyne
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - J C Gelinas
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - M I Harper
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - J P Sasso
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - N D Eves
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
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Nagel C, Benjamin N, Egenlauf B, Eichstaedt CA, Fischer C, Palevičiūtė E, Čelutkienė J, Harutyunova S, Mayer E, Nasereddin M, Marra AM, Grünig E, Guth S. Effect of Supervised Training Therapy on Pulmonary Arterial Compliance and Stroke Volume in Severe Pulmonary Arterial Hypertension and Inoperable or Persistent Chronic Thromboembolic Pulmonary Hypertension. Respiration 2021; 100:369-378. [PMID: 33765679 DOI: 10.1159/000512316] [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: 08/05/2020] [Accepted: 10/12/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pulmonary arterial compliance (PAC) is a prognostic parameter in pulmonary arterial hypertension (PAH) reflecting the elasticity of the pulmonary vessels. OBJECTIVES The objective of this post hoc analysis of a prospective randomized controlled trial (RCT) was to assess the effect of exercise training on PAC and stroke volume (SV) in patients with PAH and persistent/inoperable chronic thromboembolic pulmonary hypertension (CTEPH). METHOD From the previous RCT, 43 out of 87 patients with severe PAH (n = 29) and CTEPH (n = 14) had complete haemodynamic examinations at baseline and after 15 weeks by right heart catheterization and were analysed (53% female, 79% World Health Organization functional class III/IV, 58% combination therapy, 42% on supplemental oxygen therapy, training group n = 24, and control group n = 19). Medication remained unchanged for all patients. RESULTS Low-dose exercise training at 4-7 days/week significantly improved PAC (training group 0.33 ± 0.65 mL/mm Hg vs. control group -0.06 ± 1.10 mL/mm Hg; mean difference 0.39 mL/mm Hg, 95% confidence interval [CI] 0.15-0.94 mL/mm Hg; p = 0.004) and SV (training group 9.9 ± 13.4 mL/min vs. control group -4.2 ± 11.0 mL/min; mean difference 14.2 mL, 95% CI 6.5-21.8 mL; p < 0.001) in the training versus control group. Furthermore, exercise training significantly improved cardiac output and pulmonary vascular resistance at rest, peak oxygen consumption, and oxygen pulse. CONCLUSIONS Our findings suggest that supervised exercise training may improve right ventricular function and PAC at the same time. Further prospective studies are needed to evaluate these findings.
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Affiliation(s)
- Christian Nagel
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Department of Respiratory Care Medicine and Thoracic Surgery, Klinikum Mittelbaden, Baden-Baden Balg, Baden-Baden, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Nicola Benjamin
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Benjamin Egenlauf
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christina A Eichstaedt
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,Department of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Christine Fischer
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,Department of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Eglė Palevičiūtė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Competence Centre of Pulmonary Hypertension, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Satenik Harutyunova
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Mohammed Nasereddin
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Alberto M Marra
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,Department of Translational Medical Sciences, "Federico II" University Hospital and School of Medicine, Naples, Italy
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
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Pirlamarla P, Rame E, Hoopes C, Rajapreyar I. Pulmonary vasodilator use in continuous-flow left ventricular assist device management. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:522. [PMID: 33850919 PMCID: PMC8039680 DOI: 10.21037/atm-20-4710] [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] [Indexed: 11/19/2022]
Abstract
Pulmonary hypertension (PH) due to left heart disease is the most common etiology for PH. PH in patients with heart failure with reduced fraction (HFrEF) is associated with reduced functional capacity and increased mortality. PH-HFrEF can be isolated post-capillary or combined pre- and post-capillary PH. Chronic elevation of left-sided filling pressures may lead to reverse remodeling of the pulmonary vasculature with development of precapillary component of PH. Untreated PH in patients with HFrEF results in predominant right heart failure (RHF) with irreversible end-organ dysfunction. Management of PH-HFrEF includes diuretics, vasodilators like angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers or angiotensin-receptor blocker-neprilysin inhibitors, hydralazine and nitrates. There is no role for pulmonary vasodilator use in patients with PH-HFrEF due to increased mortality in clinical trials. In patients with end-stage HFrEF and fixed PH unresponsive to vasodilator challenge, implantation of continuous-flow left ventricular assist device (cfLVAD) results in marked improvement in pulmonary artery pressures within 6 months due to left ventricular (LV) mechanical unloading. The role of pulmonary vasodilators in management of precapillary component of PH after cfLVAD is not well-defined. The purpose of this review is to discuss the pharmacologic management of PH after cfLVAD implantation.
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Affiliation(s)
- Preethi Pirlamarla
- Advanced Heart Failure and Transplant Cardiology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Eduardo Rame
- Advanced Heart Failure and Transplant Cardiology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Charles Hoopes
- Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Indranee Rajapreyar
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama-Birmingham School of Medicine, Birmingham, AL, USA
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Papolos A, Tison GH, Mayfield J, Vasti E, DeMarco T. Echocardiographic assessment of pulmonary arterial capacitance predicts mortality in pulmonary hypertension. J Cardiol 2021; 77:279-284. [PMID: 33158713 PMCID: PMC8452137 DOI: 10.1016/j.jjcc.2020.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/07/2020] [Accepted: 09/18/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pulmonary arterial capacitance (PAC) is one of the strongest predictors of clinical outcomes in patients with pulmonary hypertension (PH). We examined the value of an echocardiographic surrogate for PAC (ePAC) as a predictor of mortality in patients with PH. METHODS We performed a retrospective study of 302 patients with PH managed at a PH comprehensive care center over a cumulative follow-up time of 858 patient-years. Charts from 2004 to 2018 were reviewed to identify patients in whom a right heart catheterization (RHC) was performed within two months of an echocardiogram. Standard invasive, non-invasive, functional, and biochemical prognostic markers were extracted from the time of RHC. The primary outcome was all-cause mortality. Cox proportional hazards models were used to model the time from RHC to the primary outcome or last medical contact. RESULTS Variables associated with all-cause mortality included ePAC [standardized hazard ratio (HR) 0.68, 95% CI 0.48-0.98, p = 0.036], RHC-PAC (HR 0.68, 95% CI 0.48-0.96, p = 0.027), echocardiographic pulmonary vascular resistance (HR 1.29, 95% CI 1.05-1.60, p = 0.017), six-minute walk distance (HR 0.43, 95% CI 0.23-0.82, p = 0.01), and B-type natriuretic peptide (HR 1.29, 95% CI 1.03-1.62, p = 0.027). In multivariable-adjusted Cox analysis, ePAC predicted all-cause mortality independently of age, gender, and multiple comorbidities. There was a graded and stepwise association between low (<0.15 cm/mmHg), medium (0.15-0.25 cm/mmHg), and high (>0.25 cm/mmHg) tertiles of ePAC and all-cause mortality. CONCLUSIONS We have demonstrated that ePAC is a readily available echocardiographic marker that independently predicts mortality in PH, and have provided clinically relevant ranges by which to risk-stratify patients and predict mortality.
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Affiliation(s)
- Alexander Papolos
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Geoffrey H Tison
- Division of Cardiology, University of California, San Francisco, CA, USA; Department of Medicine, University of California, San Francisco, CA, USA; Bakar Computational Health Sciences Institute, University of California, San Francisco, CA, USA; Cardiovascular Research Institute, University of California, San Francisco, CA, USA.
| | - Jacob Mayfield
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Elena Vasti
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Teresa DeMarco
- Division of Cardiology, University of California, San Francisco, CA, USA; Department of Medicine, University of California, San Francisco, CA, USA
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40
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Rajdev K, Lahan S, Wichman T. Role of pulmonary arterial capacitance in predicting mortality in patients with pulmonary hypertension: A systematic review and meta-analysis. Int J Cardiol 2021; 333:202-209. [PMID: 33621628 DOI: 10.1016/j.ijcard.2021.02.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/20/2021] [Accepted: 02/12/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pulmonary arterial capacitance or compliance (PAC) has been reported as an independent predictor of mortality in patients with pulmonary arterial hypertension (PAH) and pulmonary hypertension secondary to left heart disease (PH-LHD). METHODS We conducted a literature search of PubMed/Medline, Google Scholar, and Cochrane library databases from July 30th to September 4th, 2020, and identified all the relevant studies reporting mortality outcomes in patients with PAH and PH-LHD. Pooled data from these studies were used to perform a meta-analysis to identify the role of PAC in predicting all-cause mortality in this subset of patients. RESULTS Pooled data on 4997 patients from 15 individual studies showed that the mortality risk in patients with PAH and PH-LHD varies significantly per unit change in PAC either from baseline or during follow-up. A reduction in PAC per 1 ml/mmHg was associated with a 4.25 times higher risk of all-cause mortality (95% CI 1.42-12.71; p = 0.021) in PAH patients. Among patients with PH-LHD, mortality risk increased by ~30% following a unit decrease in PAC (HR, 1.29; p = 0.019), whereas an increase in PAC by 1 ml/mmHg lowered the mortality risk by 30% (HR, 0.70). CONCLUSION PAC is a strong and independent predictor of all-cause mortality in both patients with PAH and PH-LHD. A decrease in PAC by 1 ml/mmHg from baseline or during follow-up significantly increases the risk of all-cause mortality among both patients with PAH and PH-LHD. Treatment modalities targeted at PAC improvement can affect the overall survival and quality of life in such patients.
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Affiliation(s)
- Kartikeya Rajdev
- Pulmonary, Critical Care & Sleep Medicine, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Shubham Lahan
- University College of Medical Sciences, New Delhi, India
| | - Tammy Wichman
- Pulmonary, Critical Care & Sleep Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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41
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Moon J, Shen L, Likosky DS, Sood V, Hobbs RD, Sassalos P, Romano JC, Ohye RG, Bove EL, Si MS. Relationship of Ventricular Morphology and Atrioventricular Valve Function to Long-Term Outcomes Following Fontan Procedures. J Am Coll Cardiol 2021; 76:419-431. [PMID: 32703513 DOI: 10.1016/j.jacc.2020.05.059] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The influence of ventricular morphology on Fontan outcomes is controversial. OBJECTIVES This study hypothesized that dysfunction of the single right ventricle (RV) and right atrioventricular valve regurgitation (AVVR) increases over time and adversely impacts late outcomes following a Fontan operation. A single-center retrospective study was performed. METHODS From 1985 through 2018, 1,162 patients underwent the Fontan procedure at our center and were included in this study. Transplant and takedown free survival, ventricular, and atrioventricular valve dysfunction after Fontan were analyzed. Death or heart transplantation information was obtained from the National Death Index and the Scientific Registry of Transplant Recipients. RESULTS The follow-up rate was 99%. Morphologic RV was present in 58% of patients. Transplant and takedown free survival were 91%, 75%, and 71% at 10 years, 20 years, and 25 years, respectively. Morphologic RV was an independent risk factor for transplant, takedown free survival (hazard ratio: 2.4; p = 0.008). The AVVR, which preceded ventricular dysfunction in most cases, was associated with the development of ventricular dysfunction after Fontan (odds ratio: 4.3; 95% confidence interval: 2.7 to 6.7; p < 0.001). Furthermore, AVVR and ventricular dysfunction progressed over time after Fontan, especially in the RV (AVVR: p < 0.0001, ventricular dysfunction: p < 0.0001). CONCLUSIONS Morphologic RV is negatively associated with the long-term survival following the Fontan, possibly due to a tendency toward progressive AVVR and deterioration of the single ventricle function. Additional volume overload caused by AVVR may be one of the main factors accelerating the dysfunction of the single RV, implying that early valve intervention may be warranted.
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Affiliation(s)
- Jiyong Moon
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan; Division of Congenital Heart Surgery, Department of Surgery, Baylor College of Medicine Texas Children's Hospital, Houston, Texas
| | - Li Shen
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan; Department of Cardiothoracic Surgery, Shanghai Jiaotong University, Shanghai Children Hospital, Shanghai, China
| | - Donald S Likosky
- Department of Cardiac Surgery, Section of Health Services Research and Quality, University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan
| | - Vikram Sood
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Reilly D Hobbs
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Peter Sassalos
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Jennifer C Romano
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Richard G Ohye
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Edward L Bove
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Ming-Sing Si
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan.
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Wright SP, Dawkins TG, Eves ND, Shave R, Tedford RJ, Mak S. Hemodynamic function of the right ventricular-pulmonary vascular-left atrial unit: normal responses to exercise in healthy adults. Am J Physiol Heart Circ Physiol 2020; 320:H923-H941. [PMID: 33356960 DOI: 10.1152/ajpheart.00720.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
With each heartbeat, the right ventricle (RV) inputs blood into the pulmonary vascular (PV) compartment, which conducts blood through the lungs at low pressure and concurrently fills the left atrium (LA) for output to the systemic circulation. This overall hemodynamic function of the integrated RV-PV-LA unit is determined by complex interactions between the components that vary over the cardiac cycle but are often assessed in terms of mean pressure and flow. Exercise challenges these hemodynamic interactions as cardiac filling increases, stroke volume augments, and cycle length decreases, with PV pressures ultimately increasing in association with cardiac output. Recent cardiopulmonary exercise hemodynamic studies have enriched the available data from healthy adults, yielded insight into the underlying mechanisms that modify the PV pressure-flow relationship, and better delineated the normal limits of healthy responses to exercise. This review will examine hemodynamic function of the RV-PV-LA unit using the two-element Windkessel model for the pulmonary circulation. It will focus on acute PV and LA responses that accommodate increased RV output during exercise, including PV recruitment and distension and LA reservoir expansion, and the integrated mean pressure-flow response to exercise in healthy adults. Finally, it will consider how these responses may be impacted by age-related remodeling and modified by sex-related cardiopulmonary differences. Studying the determinants and recognizing the normal limits of PV pressure-flow relations during exercise will improve our understanding of cardiopulmonary mechanisms that facilitate or limit exercise.
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Affiliation(s)
- S P Wright
- Centre for Heart, Lung and Vascular Health, University of British Columbia-Okanagan, Kelowna, British Columbia, Canada
| | - T G Dawkins
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, Wales, United Kingdom
| | - N D Eves
- Centre for Heart, Lung and Vascular Health, University of British Columbia-Okanagan, Kelowna, British Columbia, Canada
| | - R Shave
- Centre for Heart, Lung and Vascular Health, University of British Columbia-Okanagan, Kelowna, British Columbia, Canada
| | - R J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - S Mak
- Division of Cardiology, Department of Medicine, Sinai Health, Toronto, Ontario, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Condliffe R. Erythrocytosis and iron status in Eisenmenger syndrome: an illustrative case study. JOURNAL OF CONGENITAL CARDIOLOGY 2020. [DOI: 10.1186/s40949-020-00045-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Patients with Eisenmenger syndrome are chronically hypoxaemic and should therefore mount a secondary erythrocytosis. This response can be attenuated by iron deficiency. Historically, patients with Eisenmenger-associated erythrocytosis often underwent venesection but recent data have challenged this practice.
Case presentation
An illustrative case of a 30-year-old female with Eisenmenger syndrome secondary to a ventricular septal defect is discussed. Her resting saturations on room air were 84%. She was receiving pulmonary arterial hypertension targeted therapy with sildenafil 25 mg three times a day and bosentan 125 mg twice daily. Her local haematologist was planning on therapeutic venesection as her haematocrit was elevated at 0.57. Her haemoglobin was 16.7 g/dl, ferritin levels were 15 μg/L and transferrin saturations were 10.5%. What are the indications for venesection? Should she receive iron supplementation instead? Data to help guide decision-making are reviewed and a clinical approach is suggested.
Conclusions
Iron status should be regularly checked in Eisenmenger syndrome patients and replaced appropriately. There is no role for routine venesection in patients with Eisenmenger syndrome; this should be reserved for the small proportion of patients with symptoms of hyperviscosity in the absence of dehydration.
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Thenappan T, Al-Naamani N, Ghio S, Ghofrani HA, Hassoun PM, Pritzker M, Torbicki A, Nikkho S, Busse D, Preston IR. Effect of riociguat on pulmonary arterial compliance in the PATENT and CHEST studies. Pulm Circ 2020; 10:2045894020963836. [PMID: 33282192 PMCID: PMC7686638 DOI: 10.1177/2045894020963836] [Citation(s) in RCA: 3] [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] [Received: 11/05/2019] [Accepted: 08/30/2020] [Indexed: 01/19/2023] Open
Abstract
Pulmonary arterial compliance is a measure of the pulsatile afterload of the
right ventricle. Lower pulmonary arterial compliance is associated with reduced
right ventricular function and worse prognosis in pulmonary hypertension. The
effect of pulmonary vasodilators on pulmonary arterial compliance has not been
evaluated in detail in pulmonary arterial hypertension or chronic thromboembolic
pulmonary hypertension. In this post hoc analysis of patients with pulmonary
arterial hypertension and chronic thromboembolic pulmonary hypertension in the
PATENT and CHEST studies, we evaluated the change in pulmonary arterial
compliance with riociguat versus placebo. Association of pulmonary arterial
compliance with clinical outcomes was assessed using Kaplan–Meier and Cox
proportional hazards analyses. Compared with placebo, riociguat significantly
improved pulmonary arterial compliance in patients with pulmonary arterial
hypertension or chronic thromboembolic pulmonary hypertension. Pulmonary
arterial compliance at baseline was associated with survival and clinical
worsening-free survival in pulmonary arterial hypertension but only with
clinical worsening-free survival in chronic thromboembolic pulmonary
hypertension. In patients with pulmonary arterial hypertension, pulmonary
arterial compliance at follow-up ≥1.6 mL/mmHg was associated with better
outcomes than pulmonary arterial compliance <1.6 mL/mmHg. In patients with
chronic thromboembolic pulmonary hypertension, pulmonary arterial compliance at
follow-up did not predict outcomes. Cox proportional hazards analyses showed no
association between change in pulmonary arterial compliance and outcomes in
patients with pulmonary arterial hypertension or chronic thromboembolic
pulmonary hypertension. In conclusion, riociguat improved pulmonary arterial
compliance in patients with pulmonary arterial hypertension or chronic
thromboembolic pulmonary hypertension. Pulmonary arterial compliance at baseline
or follow-up, rather than change in pulmonary arterial compliance, is of
prognostic importance for outcomes.
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Affiliation(s)
| | - Nadine Al-Naamani
- Pulmonary, Critical Care and Sleep Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, University Hospital, Pavia, Italy
| | - Hossein-Ardeschir Ghofrani
- Department of Medicine, University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany.,German Center of Lung Research (DZL), Giessen, Germany.,Department of Medicine, Imperial College London, London, UK
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marc Pritzker
- Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Adam Torbicki
- Department of Pulmonary Circulation and Thromboembolic Diseases, Center of Postgraduate Medical Education, ECZ-Otwock, Otwock, Poland
| | - Sylvia Nikkho
- Global Clinical Development, Bayer AG, Berlin, Germany
| | | | - Ioana R Preston
- Pulmonary, Critical Care and Sleep Division, Tufts University Medical Center, Boston, MA, USA
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Bernardo RJ, Haddad F, Couture EJ, Hansmann G, de Jesus Perez VA, Denault AY, de Man FS, Amsallem M. Mechanics of right ventricular dysfunction in pulmonary arterial hypertension and heart failure with preserved ejection fraction. Cardiovasc Diagn Ther 2020; 10:1580-1603. [PMID: 33224775 PMCID: PMC7666917 DOI: 10.21037/cdt-20-479] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022]
Abstract
Right ventricular (RV) dysfunction is the most important determinant of survival in patients with pulmonary hypertension (PH). The manifestations of RV dysfunction not only include changes in global RV systolic function but also abnormalities in the pattern of contraction and synchrony. The effects of PH on the right ventricle have been mainly studied in patients with pulmonary arterial hypertension (PAH). However, with the demographic shift towards an aging population, heart failure with preserved ejection fraction (HFpEF) has become an important etiology of PH in recent years. There are significant differences in RV mechanics, function and adaptation between patients with PAH and HFpEF (with or without PH), which are related to different patterns of remodeling and dysfunction. Due to the unique features of the RV chamber, its connection with the main pulmonary artery and the pulmonary circulation, an understanding of the mechanics of RV function and its clinical significance is mandatory for both entities. In this review, we describe the mechanics of the pressure overloaded right ventricle. We review the different mechanical components of RV dysfunction and ventricular dyssynchrony, followed by insights via analysis of pressure-volume loop, energetics and novel blood flow patterns, such as vortex imaging. We conduct an in-depth comparison of prevalence and characteristics of RV dysfunction in HFpEF and PAH, and summarize key outcome studies. Finally, we provide a perspective on needed and expected future work in the field of RV mechanics.
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Affiliation(s)
- Roberto J. Bernardo
- Division of Pulmonary, Allergy and Critical Care, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - Francois Haddad
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Etienne J. Couture
- Department of Anesthesiology, Quebec Heart and Lung Institute, Quebec, Canada
- Intensive Care Medicine Division, Department of Medicine, Quebec Heart and Lung Institute, Quebec, Canada
- Research Center, Quebec Heart and Lung Institute, Quebec, Canada
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Vinicio A. de Jesus Perez
- Division of Pulmonary, Allergy and Critical Care, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - André Y. Denault
- Department of Anesthesiology and Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Canada
- Division of Critical Care, Centre Hospitalier de l’Université de Montréal, Montreal, Canada
| | - Frances S. de Man
- Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, PHEniX laboratory, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Myriam Amsallem
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford, CA, USA
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46
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Verbelen T, Halwes M, Meyns B. First in vivo assessment of RAS-Q technology as lung support device for pulmonary hypertension. Int J Artif Organs 2020; 44:243-250. [PMID: 32907461 PMCID: PMC8041442 DOI: 10.1177/0391398820954217] [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] [Indexed: 11/27/2022]
Abstract
Objectives: To assess the in vivo hemodynamic effects on the pressure overloaded right ventricle of RAS-Q® technology, the world’s first gas exchanger with a fully integrated compliance. Methods: In six acute in vivo trials RAS-Q was implanted in sheep between the pulmonary artery and left atrium. Right ventricular pressure overload was induced by pulmonary artery banding. Pressures and flows were recorded in baseline, moderate and severe pulmonary hypertension conditions. In one trial, RAS-Q was benchmarked against the pediatric Quadrox-i®. Results: With 1.00 and 1.17 L/min, RAS-Q delivered 31% and 39% of the total cardiac output in moderate and severe pulmonary hypertension, respectively. Pulmonary artery pressures and mean pulmonary artery pressure/mean arterial blood pressure ratio successfully decreased, implying a successful right ventricular unloading. Cardiac output was restored to normal levels in both pulmonary hypertension conditions. With both devices in parallel, RAS-Q provided three times higher flow rates and a 10 times higher pressure relief, compared to the pediatric Quadrox-i. Conclusion: A gas exchanger with a fully integrated compliance better unloads the right ventricle compared to a non-compliant gas exchanger and it can restore cardiac output to normal levels in cases of severe pulmonary hypertension.
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Affiliation(s)
- Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven and Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven and Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
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Hanff TC, Birati EY. Left Ventricular Assist Device as Destination Therapy: a State of the Science and Art of Long-Term Mechanical Circulatory Support. Curr Heart Fail Rep 2020; 16:168-179. [PMID: 31631240 DOI: 10.1007/s11897-019-00438-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to synthesize and summarize recent developments in the care of patients with end-stage heart failure being managed with a left ventricular assist device (LVAD) as destination therapy. RECENT FINDINGS Although the survival of patients treated with LVAD continues to improve, the rates of LVAD-associated complication, such as right ventricular failure, bleeding complications, and major infection, remain high, and management of these patients remains challenging. The durability and hemocompatibility of LVAD support have greatly increased in recent years as a result of new technologies and novel management strategies. Challenges remain in the comprehensive care of patients with destination therapy LVADs, including management of comorbidities and optimizing patient function and quality of life.
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Affiliation(s)
- Thomas C Hanff
- Department of Medicine Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edo Y Birati
- Department of Medicine Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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48
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Metkus TS, Mathai SC, Leucker T, Hassoun PM, Tedford RJ, Korley FK. Pulmonary and systemic hemodynamics are associated with myocardial injury in the acute respiratory distress syndrome. Pulm Circ 2020; 10:2045894020939846. [PMID: 32754308 PMCID: PMC7378723 DOI: 10.1177/2045894020939846] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 06/15/2020] [Indexed: 11/25/2022] Open
Abstract
Background Whether right and left heart hemodynamics are associated with myocardial
injury in the acute respiratory distress syndrome (ARDS) is not known. Methods We performed a retrospective cohort study of subjects who had right heart
catheterization within the ALVEOLI trial and Fluid and Catheter Treatment
Trial. Myocardial injury was assessed using a highly sensitive troponin
assay (hsTn; Abbot ARCHITECT). Hemodynamic variables included right atrial
pressure, pulmonary artery wedge pressure, cardiac index and stroke volume,
pulmonary vascular resistance, pulmonary arterial compliance, and pulmonary
effective arterial elastance. We performed linear, logistic, and Cox
regression to determine the association of hemodynamic variables with
myocardial injury and to determine if hemodynamics mediated the association
between myocardial injury and death. Results Among 252 ARDS patients, median day 0 troponin was 65.4 (13.8–397.8) ng/L.
Lower cardiac index (β −0.23 SE 0.10; P < 0.001) and stroke volume (β
−0.26 SE 0.005; P < 0.001), higher pulmonary vascular resistance (β 0.22
SE 0.11; P < 0.001), lower pulmonary arterial compliance (β −0.24 SE
0.06; P < 0.001), and higher arterial elastance (β 0.27 SE 0.43;
P < 0.001) were associated with greater myocardial injury in univariable
and adjusted models. Changes in stroke volume, cardiac index, pulmonary
arterial compliance, pulmonary vascular resistance, and arterial elastance
were all associated with progressive myocardial injury over three days. hsTn
levels were associated with mortality; however, the association was
attenuated after adjustment for each of stroke volume, pulmonary vascular
resistance, pulmonary arterial compliance, and arterial elastance. Conclusion Pulmonary vascular hemodynamics are associated with myocardial injury in
ARDS, while filling pressures are not. Pulmonary vascular disease may
represent a treatable contributor to myocardial injury in ARDS.
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Affiliation(s)
- Thomas S Metkus
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Thorsten Leucker
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Ryan J Tedford
- Department of Medicine, Medical University of South Carolina, Charleston, USA
| | - Frederick K Korley
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, USA
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49
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Bashline MJ, Bachman TN, Helbling NL, Nouraie M, Gladwin MT, Simon MA. The Effects of Inhaled Sodium Nitrite on Pulmonary Vascular Impedance in Patients With Pulmonary Hypertension Associated with Heart Failure With Preserved Ejection Fraction. J Card Fail 2020; 26:654-661. [PMID: 32446946 DOI: 10.1016/j.cardfail.2020.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 04/03/2020] [Accepted: 04/10/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND The severity of pulmonary hypertension (PH) is monitored by measuring pulmonary vascular resistance, which is a steady-state measurement and ignores the pulsatile load encountered by the right ventricle (RV). Pulmonary vascular impedance (PVZ) can depict both steady-state and pulsatile forces, and thus may better predict clinical outcomes. We sought to calculate PVZ in patients with PH associated with heart failure with preserved ejection fraction who were administered inhaled sodium nitrite to better understand the acute effects on afterload. METHODS AND RESULTS Fourteen patients with PH associated with heart failure with preserved ejection fraction underwent right heart catherization and were administered inhaled sodium nitrite. A Fourier transform was used to calculate PVZ for both before and after nitrite for comparison. Inhaled sodium nitrite decreased characteristic impedance (inversely related to proximal pulmonary artery compliance) and total work performed by the RV. RV efficiency improved, defined by a reduction in the total work divided by cardiac output. There was a mild decrease in pulmonary steady-state resistance after the administration of inhaled sodium nitrite, but this effect was not significant. CONCLUSIONS PVZ analysis showed administration of inhaled sodium nitrite was associated with an improvement in pulmonary vascular compliance via a decrease in characteristic impedance, more so than pulmonary steady-state resistance. This effect was associated with improved RV efficiency and total work.
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Affiliation(s)
| | | | | | - Mehdi Nouraie
- Vascular Medicine Institute; Division of Pulmonary, Allergy and Critical Care Medicine
| | - Mark T Gladwin
- Vascular Medicine Institute; Division of Pulmonary, Allergy and Critical Care Medicine; Division of Cardiology and Heart and Vascular Institute
| | - Marc A Simon
- Department of Bioengineering; Vascular Medicine Institute; Division of Pulmonary, Allergy and Critical Care Medicine; Division of Cardiology and Heart and Vascular Institute.
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50
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Amsallem M, Tedford RJ, Denault A, Sweatt AJ, Guihaire J, Hedman K, Peighambari S, Kim JB, Li X, Miller RJH, Mercier O, Fadel E, Zamanian R, Haddad F. Quantifying the Influence of Wedge Pressure, Age, and Heart Rate on the Systolic Thresholds for Detection of Pulmonary Hypertension. J Am Heart Assoc 2020; 9:e016265. [PMID: 32419583 PMCID: PMC7428994 DOI: 10.1161/jaha.119.016265] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background The strong linear relation between mean (MPAP) and systolic (SPAP) pulmonary arterial pressure (eg, SPAP=1.62×MPAP) has been mainly reported in precapillary pulmonary hypertension. This study sought to quantify the influence of pulmonary arterial wedge pressure (PAWP), heart rate, and age on the MPAP-SPAP relation. Methods and Results An allometric equation relating invasive MPAP and SPAP was developed in 1135 patients with pulmonary arterial hypertension, advanced lung disease, chronic thromboembolic pulmonary hypertension, or left heart failure. The equation was validated in 60 885 patients from the United Network for Organ Sharing (UNOS) database referred for heart and/or lung transplant. The MPAP/SPAP longitudinal stability was assessed in pulmonary arterial hypertension with repeated right heart catheterization. The equation obtained was SPAP=1.39×MPAP×PAWP-0.07×(60/heart rate)0.12×age0.08 (P<0.001). It was validated in the UNOS cohort (R2=0.93, P<0.001), regardless of the type of organ(s) patients were listed for (mean bias [-1.96 SD; 1.96 SD] was 0.94 [-8.00; 9.88] for heart, 1.34 [-7.81; 10.49] for lung and 0.25 [-16.74; 17.24] mm Hg for heart-lung recipients). Thresholds of SPAP for MPAP=25 and 20 mm Hg were lower in patients with higher PAWP (37.2 and 29.8 mm Hg) than in those with pulmonary arterial hypertension (40.1 and 32.0 mm Hg). In 186 patients with pulmonary arterial hypertension, the predicted MPAP/SPAP was stable over time (0.63±0.03 at baseline and follow-up catheterization, P=0.43). Conclusions This study quantifies the impact of PAWP, and to a lesser extent heart rate and age, on the MPAP-SPAP relation, supporting lower SPAP thresholds for pulmonary hypertension diagnosis in patients with higher PAWP for echocardiography-based epidemiological studies.
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Affiliation(s)
- Myriam Amsallem
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA.,Stanford Cardiovascular Institute Stanford University School of Medicine Stanford CA
| | - Ryan J Tedford
- Division of Cardiology Department of Medicine Medical University of South Carolina Charleston SC
| | - Andre Denault
- Department of Anesthesiology and Division of Critical Care Montreal Heart Institute Université de Montréal Quebec Canada
| | - Andrew J Sweatt
- Division of Pulmonary and Critical Care Medicine Stanford University School of Medicine Stanford CA.,Vera Moulton Wall Center for Pulmonary Disease at Stanford University Stanford CA
| | - Julien Guihaire
- Research and Innovation Unit INSERM U999 DHU TORINO Paris Sud University Marie Lannelongue Hospital Le Plessis Robinson France
| | - Kristofer Hedman
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA.,Department of Medical and Health Sciences Linköping University Linköping Sweden
| | - Shadi Peighambari
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA
| | - Juyong Brian Kim
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA.,Stanford Cardiovascular Institute Stanford University School of Medicine Stanford CA
| | - Xiao Li
- Department of Genetics Stanford University School of Medicine Stanford CA
| | - Robert J H Miller
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA
| | - Olaf Mercier
- Research and Innovation Unit INSERM U999 DHU TORINO Paris Sud University Marie Lannelongue Hospital Le Plessis Robinson France
| | - Elie Fadel
- Research and Innovation Unit INSERM U999 DHU TORINO Paris Sud University Marie Lannelongue Hospital Le Plessis Robinson France
| | - Roham Zamanian
- Division of Pulmonary and Critical Care Medicine Stanford University School of Medicine Stanford CA.,Vera Moulton Wall Center for Pulmonary Disease at Stanford University Stanford CA
| | - Francois Haddad
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA.,Stanford Cardiovascular Institute Stanford University School of Medicine Stanford CA
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