1
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Colunga A, Carlson BE, Olufsen MS. The importance of incorporating ventricular-ventricular interaction (VVI) in the study of pulmonary hypertension. Math Biosci 2024; 375:109242. [PMID: 38944112 DOI: 10.1016/j.mbs.2024.109242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 06/18/2024] [Accepted: 06/22/2024] [Indexed: 07/01/2024]
Abstract
Ventricular ventricular interaction (VVI) affects blood volume and pressure in the right and left ventricles of the heart due to the location and balance of forces on the septal wall separating the ventricles. In healthy patients, the pressure of the left ventricle is considerably higher than the right, resulting in a septal wall that bows into the right ventricle. However, in patients with pulmonary hypertension, the pressure in the right ventricle increases significantly to a point where the pressure is similar to or surpasses that of the left ventricle during portions of the cardiac cycle. For these patients, the septal wall deviates towards the left ventricle, impacting its function. It is possible to study this effect using mathematical modeling, but existing models are nonlinear, leading to a system of algebraic differential equations that can be challenging to solve in patient-specific optimizations of clinical data. This study demonstrates that a simplified linearized model is sufficient to account for the effect of VVI and that, as expected, the impact is significantly more pronounced in patients with pulmonary hypertension.
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Affiliation(s)
- Amanda Colunga
- North Carolina State University, 2311 Stinson Drive, Raleigh, 27695, NC, USA
| | - Brian E Carlson
- University of Michigan, 2800 Plymouth Rd, Ann Arbor, 48105, MI, USA
| | - Mette S Olufsen
- North Carolina State University, 2311 Stinson Drive, Raleigh, 27695, NC, USA.
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2
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Taboni A, Fagoni N, Fontolliet T, Vinetti G, Ferretti G. Baroreflex dynamics during the rest to exercise transient in acute normobaric hypoxia in humans. Eur J Appl Physiol 2024; 124:2765-2775. [PMID: 38656378 PMCID: PMC11365845 DOI: 10.1007/s00421-024-05485-4] [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: 01/24/2024] [Accepted: 03/26/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE We hypothesised that during a rest-to-exercise transient in hypoxia (H), compared to normoxia (N), (i) the initial baroreflex sensitivity (BRS) decrease would be slower and (ii) the fast heart rate (HR) and cardiac output (CO) response would have smaller amplitude (A1) due to lower vagal activity in H than N. METHODS Ten participants performed three rest-to-50 W exercise transients on a cycle-ergometer in N (ambient air) and three in H (inspired fraction of O2 = 0.11). R-to-R interval (RRi, by electrocardiography) and blood pressure profile (by photo-plethysmography) were recorded non-invasively. Analysis of the latter provided mean arterial pressure (MAP) and stroke volume (SV). CO = HR·SV. BRS was calculated by modified sequence method. RESULTS Upon exercise onset in N, MAP fell to a minimum (MAPmin) then recovered. BRS decreased immediately from 14.7 ± 3.6 at rest to 7.0 ± 3.0 ms mmHg-1 at 50 W (p < 0.01). The first BRS sequence detected at 50 W was 8.9 ± 4.8 ms mmHg-1 (p < 0.05 vs. rest). In H, MAP showed several oscillations until reaching a new steady state. BRS decreased rapidly from 10.6 ± 2.8 at rest to 2.9 ± 1.5 ms mmHg-1 at 50 W (p < 0.01), as the first BRS sequence at 50 W was 5.8 ± 2.6 ms mmHg-1 (p < 0.01 vs. rest). CO-A1 was 2.96 ± 1.51 and 2.31 ± 0.94 l min-1 in N and H, respectively (p = 0.06). HR-A1 was 7.7 ± 4.6 and 7.1 ± 5.9 min-1 in N and H, respectively (p = 0.81). CONCLUSION The immediate BRS decrease in H, coupled with similar rapid HR and CO responses, is compatible with a withdrawal of residual vagal activity in H associated with increased sympathetic drive.
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Affiliation(s)
- Anna Taboni
- Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, Brescia, Italy.
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.
- Department of Anaesthesiology, Pharmacology, Intensive Care, and Emergencies, University of Geneva, Geneva, Switzerland.
| | - Nazzareno Fagoni
- Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, Brescia, Italy
- Department of Anaesthesiology, Pharmacology, Intensive Care, and Emergencies, University of Geneva, Geneva, Switzerland
| | - Timothée Fontolliet
- Department of Anaesthesiology, Pharmacology, Intensive Care, and Emergencies, University of Geneva, Geneva, Switzerland
| | - Giovanni Vinetti
- Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, Brescia, Italy
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Guido Ferretti
- Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, Brescia, Italy
- Department of Anaesthesiology, Pharmacology, Intensive Care, and Emergencies, University of Geneva, Geneva, Switzerland
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3
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Hemnes AR, Celermajer DS, D'Alto M, Haddad F, Hassoun PM, Prins KW, Naeije R, Vonk Noordegraaf A. Pathophysiology of the right ventricle and its pulmonary vascular interaction. Eur Respir J 2024:2401321. [PMID: 39209482 DOI: 10.1183/13993003.01321-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 07/09/2024] [Indexed: 09/04/2024]
Abstract
The right ventricle and its stress response is perhaps the most important arbiter of survival in patients with pulmonary hypertension of many causes. The physiology of the cardiopulmonary unit and definition of right heart failure proposed in the 2018 World Symposium on Pulmonary Hypertension have proven useful constructs in subsequent years. Here, we review updated knowledge of basic mechanisms that drive right ventricular function in health and disease, and which may be useful for therapeutic intervention in the future. We further contextualise new knowledge on assessment of right ventricular function with a focus on metrics readily available to clinicians and updated understanding of the roles of the right atrium and tricuspid regurgitation. Typical right ventricular phenotypes in relevant forms of pulmonary vascular disease are reviewed and recent studies of pharmacological interventions on chronic right ventricular failure are discussed. Finally, unanswered questions and future directions are proposed.
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Affiliation(s)
- Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David S Celermajer
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michele D'Alto
- Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University and Stanford Cardiovascular Institute, Palo Alto, CA, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kurt W Prins
- Lillehei Heart Institute, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Anton Vonk Noordegraaf
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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4
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Keramida K, Farmakis D, Rakisheva A, Tocchetti CG, Ameri P, Asteggiano R, Barac A, Bax J, Bayes-Genis A, Bergler Klein J, Bucciarelli-Ducci C, Celutkiene J, Coats AJS, Cohen Solal A, Dent S, Filippatos G, Ghosh A, Hermann J, Koop Y, Lenihan D, Lopez Fernandez T, Lyon AR, Mercurio V, Moura B, Piepoli M, Sener YZ, Suter T, Sverdlov AL, Tadic M, Thum T, van der Meer P, van Linthout S, Metra M, Rosano G. The right heart in patients with cancer. A scientific statement of the Heart Failure Association (HFA) of the ESC and the ESC Council of Cardio-Oncology. Eur J Heart Fail 2024. [PMID: 39193837 DOI: 10.1002/ejhf.3412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 07/24/2024] [Accepted: 07/30/2024] [Indexed: 08/29/2024] Open
Affiliation(s)
- Kalliopi Keramida
- Cardiology Department, General Anti-Cancer Oncological Hospital Agios Savvas, Athens, Greece
| | - Dimitrios Farmakis
- Department of Cardiology, Athens University Hospital Attikon, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Amina Rakisheva
- City Cardiological Center, Almaty, Kazakhstan, Qonaev City Hospital, Almaty Region, Almaty, Kazakhstan
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences (DISMET), 'Federico II' University, Naples, Italy
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), 'Federico II' University, Naples, Italy
- Interdepartmental Hypertension Research Center (CIRIAPA), 'Federico II' University, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), 'Federico II' University, Naples, Italy
| | - Pietro Ameri
- Department of Internal Medicine, University of Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Riccardo Asteggiano
- Internal Medicine, Department of Medicine and Surgery, University of Insubria, Varese, Italy
- LARC, Laboratorio Analisi e Ricerca Clinica, Turin, Italy
| | - Ana Barac
- MedStar Heart and Vascular Institute, Georgetown University, Washington, DC, USA
| | - Jeroen Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Antoni Bayes-Genis
- CIBER Cardiovascular, Madrid, Spain
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | | | - Jelena Celutkiene
- Centre of Cardiology and Angiology, Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | | | - Alain Cohen Solal
- Université Paris Cité, INSERM U-942 MASCOT, Cardiology Department, Lariboisière Hospital, Paris, France
| | - Susan Dent
- Duke Cancer Institute, Department of Medicine, Duke University, Durham, NC, USA
| | - Gerasimos Filippatos
- Department of Cardiology, Athens University Hospital Attikon, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Arjun Ghosh
- Barts Heart Centre, University College London Hospital and Hatter Cardiovascular Institute, London, UK
| | - Joerg Hermann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yvonne Koop
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Daniel Lenihan
- Cardio-Oncology Program, St Francis Healthcare, Cape Girardeau, MO, USA
| | - Teresa Lopez Fernandez
- Cardiology Department, La Paz University Hospital, IdiPAZ Research Institute, Madrid, Spain
- Cardiology Department, Hospital Universitario Quirónsalud Madrid, Madrid, Spain
| | - Alexander R Lyon
- National Heart and Lung Institute, Imperial College London and Cardio-Oncology Service, Royal Brompton Hospital, London, UK
| | - Valentina Mercurio
- Department of Translational Medical Sciences (DISMET), 'Federico II' University, Naples, Italy
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), 'Federico II' University, Naples, Italy
- Interdepartmental Hypertension Research Center (CIRIAPA), 'Federico II' University, Naples, Italy
| | - Brenda Moura
- Armed Forces Hospital, Porto and Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Massimo Piepoli
- Clinical Cardiology, IRCCS Policlinico San Donato, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | | | - Thomas Suter
- Cardiology Department, University of Ulm, Ulm, Germany
| | - Aaron L Sverdlov
- Newcastle Centre of Excellence in Cardio-Oncology, The University of Newcastle, Hunter Medical Research Institute, Calvary Mater Newcastle, Hunter New England Health, Newcastle, NSW, Australia
- Cardiovascular Department, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Marijana Tadic
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Ulm, Germany
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
- Fraunhofer Cluster of Excellence Immune-Mediated Diseases (CIMD), Hannover, Germany
- Fraunhofer Institute for Toxicology and Experimental Medicine (ITEM), Hannover, Germany
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sophie van Linthout
- Berlin Institute of Health (BIH) at Charité, BIH Center for Regenerative Therapies, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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5
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Ren M, Chan WX, Green L, Buist ML, Yap CH. Biventricular finite element modeling of the fetal heart in health and during critical aortic stenosis. Biomech Model Mechanobiol 2024; 23:1331-1345. [PMID: 38589684 DOI: 10.1007/s10237-024-01842-6] [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: 09/12/2023] [Accepted: 03/15/2024] [Indexed: 04/10/2024]
Abstract
Finite Element simulations are a robust way of investigating cardiac biomechanics. To date, it has only been performed with the left ventricle (LV) alone for fetal hearts, even though results are likely different with biventricular (BiV) simulations. In this research, we conduct BiV simulations of the fetal heart based on 4D echocardiography images to show that it can capture the biomechanics of the normal healthy fetal heart, as well as those of fetal aortic stenosis better than the LV alone simulations. We found that performing LV alone simulations resulted in overestimation of LV stresses and pressures, compared to BiV simulations. Interestingly, inserting a compliance between the LV and right ventricle (RV) in the lumped parameter model of the LV only simulation effectively resolved these overestimations, demonstrating that the septum could be considered to play a LV-RV pressure communication role. However, stresses and strains spatial patterns remained altered from BiV simulations after the addition of the compliance. The BiV simulations corroborated previous studies in showing disease effects on the LV, where fetal aortic stenosis (AS) drastically elevated LV pressures and reduced strains and stroke volumes, which were moderated down with the addition of mitral regurgitation (MR). However, BiV simulations enabled an evaluation of the RV as well, where we observed that effects of the AS and MR on pressures and stroke volumes were generally much smaller and less consistent. The BiV simulations also enabled investigations of septal dynamics, which showed a rightward shift with AS, and partial restoration with MR. Interestingly, AS tended to enhance RV stroke volume, but MR moderated that down.
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Affiliation(s)
- Meifeng Ren
- Department of Biomedical Engineering, National University of Singapore, 4, Engineering Drive 3, E4-04-08, Singapore, 117583, Singapore
| | - Wei Xuan Chan
- Department of Bioengineering, Imperial College London, L2 Bessemer Building, South Kensington Campus, London, SW7 2AZ, UK
| | - Laura Green
- Department of Bioengineering, Imperial College London, L2 Bessemer Building, South Kensington Campus, London, SW7 2AZ, UK
| | - Martin L Buist
- Department of Biomedical Engineering, National University of Singapore, 4, Engineering Drive 3, E4-04-08, Singapore, 117583, Singapore.
| | - Choon Hwai Yap
- Department of Bioengineering, Imperial College London, L2 Bessemer Building, South Kensington Campus, London, SW7 2AZ, UK.
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6
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Holden KI, Rintoul NE, McNamara PJ, Harting MT. Congenital diaphragmatic hernia-associated pulmonary hypertension. Semin Pediatr Surg 2024; 33:151437. [PMID: 39018718 DOI: 10.1016/j.sempedsurg.2024.151437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
Congenital diaphragmatic hernia (CDH) is characterized by a developmental insult which compromises cardiopulmonary embryology and results in a diaphragmatic defect, allowing abdominal organs to herniate into the hemithorax. Among the significant pathophysiologic components of this condition is pulmonary hypertension (PH), alongside pulmonary hypoplasia and cardiac dysfunction. Fetal pulmonary vascular development coincides with lung development, with the pulmonary vasculature evolving alongside lung maturation. However, in CDH, this embryologic development is impaired which, in conjunction with external compression, stifle pulmonary vascular maturation, leading to reduced lung density, increased muscularization of the pulmonary vasculature, abnormal vascular responsiveness, and altered molecular signaling, all contributing to pulmonary arterial hypertension. Understanding CDH-associated PH (CDH-PH) is crucial for development of novel approaches and effective management due to its significant impact on morbidity and mortality. Antenatal and postnatal diagnostic methods aid in CDH risk stratification and, specifically, pulmonary hypertension, including fetal imaging and gas exchange assessments. Management strategies include lung protective ventilation, fluid optimization, pharmacotherapies including pulmonary vasodilators and hemodynamic support, and extracorporeal life support (ECLS) for refractory cases. Longitudinal re-evaluation is an important consideration due to the complexity and dynamic nature of CDH cardiopulmonary physiology. Emerging therapies such as fetal endoscopic tracheal occlusion and pharmacological interventions targeting key CDH pathophysiological mechanisms show promise but require further investigation. The complexity of CDH-PH underscores the importance of a multidisciplinary approach for optimal patient care and improved outcomes.
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MESH Headings
- Hernias, Diaphragmatic, Congenital/complications
- Hernias, Diaphragmatic, Congenital/therapy
- Hernias, Diaphragmatic, Congenital/physiopathology
- Humans
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/therapy
- Hypertension, Pulmonary/physiopathology
- Infant, Newborn
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Affiliation(s)
- Kylie I Holden
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Natalie E Rintoul
- Department of Neonatology, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Patrick J McNamara
- Division of Neonatology, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, USA.
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7
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Altit G, Lapointe A, Kipfmueller F, Patel N. Cardiac function in congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151438. [PMID: 39018716 DOI: 10.1016/j.sempedsurg.2024.151438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
Cardiac function is known to play critical role in the pathophysiological progression and ultimate clinical outcome of patients with congenital diaphragmatic hernia (CDH). While often anatomically normal, the fetal and neonatal heart in CDH can suffer from both right and left ventricular dysfunction. Here we explore the abnormal fetal heart, early postnatal right and left ventricular dysfunction, the interplay between cardiac dysfunction and pulmonary hypertension, evaluation and echocardiographic assessment of the heart, and therapeutic strategies for managing and supporting the pathophysiologic heart and CDH. Further, we take a common clinical scenario and provide clinically relevant guidance for the diagnosis and management of this complex process.
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MESH Headings
- Humans
- Hernias, Diaphragmatic, Congenital/diagnosis
- Hernias, Diaphragmatic, Congenital/physiopathology
- Hernias, Diaphragmatic, Congenital/complications
- Hernias, Diaphragmatic, Congenital/therapy
- Infant, Newborn
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/physiopathology
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/diagnosis
- Echocardiography
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Dysfunction, Right/etiology
- Ventricular Dysfunction, Right/diagnosis
- Fetal Heart/diagnostic imaging
- Fetal Heart/physiopathology
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Affiliation(s)
- Gabriel Altit
- Division of Neonatology, Montreal Children's Hospital, McGill University Health Centre, Montréal, Canada
| | - Anie Lapointe
- Division of Neonatology, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Canada
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care Medicine, Children's Hospital University of Bonn, Germany
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, UK.
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8
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Gutierrez-Gallegos P, Jimenez-Franco V, Jerjes-Sanchez C, Quevedo-Salazar R, Rodriguez-Rivera J, Paredes-Gutierrez E, Lira-Lozano D, Quintanilla-Gutierrez J, Gomez-Gutierrez R, de la Peña-Almaguer E, Torre-Amione G. Successful pharmaco-invasive approach using a lower alteplase dose and VA-ECMO support in high-risk pulmonary embolism: case report. Front Cardiovasc Med 2024; 11:1444636. [PMID: 39105076 PMCID: PMC11298445 DOI: 10.3389/fcvm.2024.1444636] [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: 06/06/2024] [Accepted: 07/10/2024] [Indexed: 08/07/2024] Open
Abstract
Despite the elevated mortality rates associated with high-risk pulmonary embolism (PE), this condition remains understudied. Data regarding the effectiveness and safety of invasive therapies such as venoarterial extracorporeal membrane oxygenation (VA-ECMO) in this patient population remains controversial. Here, we present the case of a 61-year-old male with high-risk PE associated with refractory cardiac arrest and cardiogenic shock who underwent a combination of extracorporeal cardiopulmonary resuscitation with VA-ECMO and pharmaco-invasive therapy (mechanical thrombi fragmentation plus lower alteplase dose), resulting in successful pulmonary reperfusion. After a prolonged in-hospital stay, the patient was discharged in stable condition.
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Affiliation(s)
| | - Vicente Jimenez-Franco
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
- Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza Garcia, Mexico
- Shock Team, Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza Garcia, Mexico
| | - Carlos Jerjes-Sanchez
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
- Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza Garcia, Mexico
| | | | | | | | - Daniel Lira-Lozano
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
- Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza Garcia, Mexico
| | - Juan Quintanilla-Gutierrez
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
- Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza Garcia, Mexico
- Shock Team, Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza Garcia, Mexico
| | - Rene Gomez-Gutierrez
- Shock Team, Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza Garcia, Mexico
| | - Erasmo de la Peña-Almaguer
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
- Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza Garcia, Mexico
- Shock Team, Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza Garcia, Mexico
| | - Guillermo Torre-Amione
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
- Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza Garcia, Mexico
- Shock Team, Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza Garcia, Mexico
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9
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Cadour F, Sourdon J, Rapacchi S. Editorial for "Biventricular Dysfunction and Ventricular Interdependence in Patients With Pulmonary Hypertension: A 3.0-T Cardiac MRI Feature Tracking Study". J Magn Reson Imaging 2024; 60:363-364. [PMID: 37905953 DOI: 10.1002/jmri.29092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 10/06/2023] [Indexed: 11/02/2023] Open
Affiliation(s)
- Farah Cadour
- Department of Medical Imaging, University of Toronto, University Medical Imaging Toronto, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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10
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Vaidyanathan B, Soman S, Karmegaraj B. Utility of the novel fetal heart quantification (fetal HQ) technique in diagnosing ventricular interdependence and biventricular dysfunction in a case of prenatally diagnosed Uhl's anomaly. Echocardiography 2024; 41:e15862. [PMID: 38943481 DOI: 10.1111/echo.15862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 05/26/2024] [Accepted: 05/30/2024] [Indexed: 07/01/2024] Open
Abstract
Uhl's anomaly is characterized by complete or partial absence of right ventricular myocardium. We describe a case of prenatally diagnosed Uhl's anomaly with biventricular dysfunction which was quantified with speckle tracking echocardiography using a novel fetal heart quantification (fetal HQ) technique.
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Affiliation(s)
- Balu Vaidyanathan
- The Fetal cardiology unit, Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Sruthi Soman
- The Fetal cardiology unit, Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Balaganesh Karmegaraj
- The Fetal cardiology unit, Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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11
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Ramoni D, Carbone F, Montecucco F. Ultrasound unveiling: Decoding venous congestion in heart failure for precision management of fluid status. World J Cardiol 2024; 16:306-309. [PMID: 38993587 PMCID: PMC11235209 DOI: 10.4330/wjc.v16.i6.306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/13/2024] [Accepted: 06/11/2024] [Indexed: 06/24/2024] Open
Abstract
This editorial discusses the manuscript by Di Maria et al, published in the recent issue of the World Journal of Cardiology. We here focus on the still elusive pathophysiological mechanisms underlying cardio-renal syndrome (CRS), despite its high prevalence and the substantial worsening of both kidney function and heart failure. While the measure of right atrial pressure through right cardiac catheterization remains the most accurate albeit invasive and costly procedure, integrating bedside ultrasound into diagnostic protocols may substantially enhance the staging of venous congestion and guide therapeutic decisions. In particular, with the assessment of Doppler patterns across multiple venous districts, the Venous Excess Ultrasound (VExUS) score improves the management of fluid overload and provides insight into the underlying factors contributing to cardio-renal interactions. Integrating specific echocardiographic parameters, particularly those concerning the right heart, may thus improve the VExUS score sensitivity, offering perspective into the nuanced comprehension of cardio-renal dynamics. A multidisciplinary approach that consistently incorporates the use of ultrasound is emerging as a promising advance in the understanding and management of CRS.
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Affiliation(s)
- Davide Ramoni
- Department of Internal Medicine, University of Genoa, Genoa 16132, Italy
| | - Federico Carbone
- Department of Internal Medicine, University of Genoa, Genoa 16132, Italy
- Department of Internal Medicine, IRCCS Ospedale Policlinico San Martino, Genoa 16132, Italy
| | - Fabrizio Montecucco
- Department of Internal Medicine, University of Genoa, Genoa 16132, Italy
- Department of Internal Medicine, IRCCS Ospedale Policlinico San Martino, Genoa 16132, Italy.
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12
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Kapur NK, Kanwar MK, Yousefzai R, Bhimiraj A, Farber H, Esposito ML, Kiernan MS, John KJ, Burkhoff D. Mechanical Preload Reduction: Harnessing a Cornerstone of Heart Failure Management to Improve Clinical Outcomes. ASAIO J 2024:00002480-990000000-00499. [PMID: 38829983 DOI: 10.1097/mat.0000000000002240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
Decongestion is a cornerstone therapeutic goal for those presenting with decompensated heart failure. Current approaches to clinical decongestion include reducing cardiac preload, which is typically limited to diuretics and hemofiltration. Several new technologies designed to mechanically reduce cardiac preload are in development. In this review, we discuss the pathophysiology of decompensated heart failure; the central role of targeting cardiac preload; emerging mechanical preload reduction technologies; and potential application of these devices.
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Affiliation(s)
- Navin K Kapur
- From the Department of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Manreet K Kanwar
- Department of Cardiology, Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Rayan Yousefzai
- Department of Cardiology, Houston Methodist Research Institute, Houston, Texas
| | - Arvind Bhimiraj
- Department of Cardiology, Houston Methodist Research Institute, Houston, Texas
| | - Harrison Farber
- From the Department of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Michele L Esposito
- Department of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Michael S Kiernan
- From the Department of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Kevin J John
- From the Department of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Daniel Burkhoff
- Department of Cardiology, The Cardiovascular Research Foundation, New York, New York
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13
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Lui JK, Cozzolino M, Winburn M, Trojanowski MA, Wiener RS, LaValley MP, Bujor AM, Gopal DM, Klings ES. Role of Left Ventricular Dysfunction in Systemic Sclerosis-Related Pulmonary Hypertension. Chest 2024; 165:1505-1517. [PMID: 38128607 PMCID: PMC11177103 DOI: 10.1016/j.chest.2023.12.018] [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: 05/08/2023] [Revised: 11/11/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND In systemic sclerosis (SSc), pulmonary hypertension remains a significant cause of morbidity and mortality. Although conventionally classified as group 1 pulmonary arterial hypertension, systemic sclerosis-related pulmonary hypertension (SSc-PH) is a heterogeneous disease. The contribution of left-sided cardiac disease in SSc-PH remains poorly understood. RESEARCH QUESTION How often does left ventricular (LV) dysfunction occur in SSc among patients undergoing right heart catheterization and how does coexistent LV dysfunction with SSc-PH affect all-cause mortality in this patient population? STUDY DESIGN AND METHODS We conducted a retrospective, observational study of 165 patients with SSc who underwent both echocardiography and right heart catheterization. LV dysfunction was identified using LV global longitudinal strain (GLS) on speckle-tracking echocardiography based on a defined threshold of > -18%. SSc-PH was defined by a mean pulmonary artery pressure > 20 mmHg. RESULTS Among patients with SSc who have undergone right heart catheterization, LV dysfunction occurred in 74.2% with SSc-PH and 51.2% without SSc-PH. The median survival of patients with SSc-PH and LV dysfunction was 67.9 (95% CI, 38.3-102.0) months, with a hazard ratio of 12.64 (95% CI, 1.73-92.60) for all-cause mortality when adjusted for age, sex, SSc disease duration, and FVC compared with patients with SSc without pulmonary hypertension with normal LV function. INTERPRETATION LV dysfunction is common in SSc-PH. Patients with SSc-PH and LV dysfunction by LV GLS have increased all-cause mortality. This suggests that LV GLS may be helpful in identifying underlying LV dysfunction and in risk assessment of patients with SSc-PH.
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Affiliation(s)
- Justin K Lui
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
| | - Matthew Cozzolino
- Section of Cardiovascular Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Morgan Winburn
- Section of Cardiovascular Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Marcin A Trojanowski
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Renda Soylemez Wiener
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA
| | - Michael P LaValley
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Andreea M Bujor
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Deepa M Gopal
- Section of Cardiovascular Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Elizabeth S Klings
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
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14
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Yamamoto A, Nagao M, Kawakubo M, Nakao R, Matsuo Y, Sakai A, Kaneko K, Fukushima K, Momose M, Sakai S, Yamaguchi J. Risk Stratification Using Right Ventricular Longitudinal Strain Ratio Derived from 13N-Ammonia PET in Patients with Ischemic Heart Disease. Radiol Cardiothorac Imaging 2024; 6:e230298. [PMID: 38814185 PMCID: PMC11211937 DOI: 10.1148/ryct.230298] [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: 09/21/2023] [Revised: 03/18/2024] [Accepted: 04/15/2024] [Indexed: 05/31/2024]
Abstract
Purpose To investigate whether right ventricular (RV) myocardial strain ratio (RVMSR) assessed using nitrogen 13 ammonia (13N-NH3) PET can predict cardiovascular events in patients with ischemic heart disease (IHD). Materials and Methods This retrospective study included 480 consecutive patients (mean age, 66 years ± 12 [SD]; 334 males and 146 females) with IHD who underwent 13N-NH3 PET. RVMSR was defined as the ratio of RV strain during stress to that at rest. The primary end point was major adverse cardiac events (MACEs), defined as cardiac death or heart failure hospitalization. The ability of RVMSR to predict MACE was assessed using receiver operating characteristic (ROC) curve and Kaplan-Meier analyses. Cox proportional hazards regression analysis was used to calculate hazard ratios (HRs) with 95% CIs. Results ROC curve analysis identified a sensitivity and specificity of 84% and 82%, respectively, for predicting MACE from RVMSR. Patients with reduced RVMSR (<110.2) displayed a significantly higher rate of MACE than those with a preserved RVMSR (34 of 240 vs four of 240; P < .001). Cox proportional hazards regression analysis of imaging parameters, including myocardial flow reserve, indicated that RVMSR was an independent predictor of MACE (HR, 0.94 [95% CI: 0.92, 0.97]; P < .001). Conclusion RVMSR was an independent predictor of MACE and has potential to aid in the risk stratification of patients with IHD. Keywords: Right Ventricular Myocardial Strain Ratio, Myocardial Flow Reserve, Ischemic Heart Disease, 13N-Ammonia Positron Emission Tomography Supplemental material is available for this article. © RSNA, 2024.
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Affiliation(s)
- Atsushi Yamamoto
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and
Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K.,
M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho,
Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of
Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of
Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan
(K.F.)
| | - Michinobu Nagao
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and
Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K.,
M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho,
Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of
Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of
Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan
(K.F.)
| | - Masateru Kawakubo
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and
Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K.,
M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho,
Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of
Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of
Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan
(K.F.)
| | - Risako Nakao
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and
Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K.,
M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho,
Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of
Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of
Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan
(K.F.)
| | - Yuka Matsuo
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and
Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K.,
M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho,
Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of
Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of
Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan
(K.F.)
| | - Akiko Sakai
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and
Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K.,
M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho,
Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of
Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of
Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan
(K.F.)
| | - Koichiro Kaneko
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and
Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K.,
M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho,
Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of
Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of
Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan
(K.F.)
| | - Kenji Fukushima
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and
Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K.,
M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho,
Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of
Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of
Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan
(K.F.)
| | - Mitsuru Momose
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and
Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K.,
M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho,
Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of
Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of
Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan
(K.F.)
| | - Shuji Sakai
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and
Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K.,
M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho,
Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of
Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of
Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan
(K.F.)
| | - Junichi Yamaguchi
- From the Department of Cardiology (A.Y., R.N., A.S., J.Y.) and
Department of Diagnostic Imaging and Nuclear Medicine (A.Y., M.N., Y.M., K.K.,
M.M., S.S.), Tokyo Women's Medical University, 8-1 Kawada-cho,
Shinjuku-ku, Tokyo, Japan 162-8666; Department of Health Sciences, Faculty of
Medical Sciences, Kyushu University, Fukuoka, Japan (M.K.); and Department of
Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan
(K.F.)
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15
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Nagai Y, Murayama M, Kaga S, Shima H, Tsuneta S, Yokoyama S, Nishino H, Goto M, Suzuki Y, Yanagi Y, Ishizaka S, Iwano H, Nakamura J, Sato T, Tsujino I. Echocardiographic estimation of right ventricular diastolic stiffness based on pulmonary regurgitant velocity waveform analysis in precapillary pulmonary hypertension. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:1123-1134. [PMID: 38536607 DOI: 10.1007/s10554-024-03083-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 03/09/2024] [Indexed: 06/05/2024]
Abstract
Right ventricular (RV) diastolic stiffness is an independent predictor of survival and is strongly associated with disease severity in patients with precapillary pulmonary hypertension (PH). Therefore, a fully validated echocardiographic method for assessing RV diastolic stiffness needs to be established. This study aimed to compare echocardiography-derived RV diastolic stiffness and invasively measured pressure-volume loop-derived RV diastolic stiffness in patients with precapillary PH. We studied 50 consecutive patients with suspected or confirmed precapillary PH who underwent cardiac catheterization, magnetic resonance imaging, and echocardiography within a 1-week interval. Single-beat RV pressure-volume analysis was performed to determine the gold standard for RV diastolic stiffness. Elevated RV end-diastolic pressure (RVEDP) was defined as RVEDP ≥ 8 mmHg. Using continuous-wave Doppler and M-mode echocardiography, an echocardiographic index of RV diastolic stiffness was calculated as the ratio of the atrial-systolic descent of the pulmonary artery-RV pressure gradient derived from pulmonary regurgitant velocity (PRPGDAC) to the tricuspid annular plane movement during atrial contraction (TAPMAC). PRPGDAC/TAPMAC showed significant correlation with β (r = 0.54, p < 0.001) and RVEDP (r = 0.61, p < 0.001). A cut-off value of 0.74 mmHg/mm for PRPGDAC/TAPMAC showed 83% sensitivity and 93% specificity for identifying elevated RVEDP. Multivariate analyses indicated that PRPGDAC/TAPMAC was independently associated with disease severity in patients with precapillary PH, including substantial PH symptoms, stroke volume index, right atrial size, and pressure. PRPGDAC/TAPMAC, based on pulmonary regurgitation velocity waveform analysis, is useful for the noninvasive assessment of RV diastolic stiffness and is associated with prognostic risk factors in precapillary PH.
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Affiliation(s)
- Yui Nagai
- Graduate School of Health Sciences, Hokkaido University, N12, W5, Kita-ku, Sapporo, 060-0812, Japan
| | - Michito Murayama
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University, N12, W5, Kita-ku, Sapporo, 060-0812, Japan
| | - Sanae Kaga
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University, N12, W5, Kita-ku, Sapporo, 060-0812, Japan.
| | - Hideki Shima
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Satonori Tsuneta
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, N14 W5, Kita-Ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Shinobu Yokoyama
- Diagnostic Center for Sonography, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Hisao Nishino
- Diagnostic Center for Sonography, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Mana Goto
- Diagnostic Center for Sonography, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Yukino Suzuki
- Diagnostic Center for Sonography, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Yusuke Yanagi
- Diagnostic Center for Sonography, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Suguru Ishizaka
- Diagnostic Center for Sonography, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
- Department of Cardiovascular Medicine, Faculty of Medicine, Graduate School of Medicine, Hokkaido University, N15, W7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hiroyuki Iwano
- Diagnostic Center for Sonography, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
- Division of Cardiology, Teine Keijinkai Hospital, 1-40, Maeda 1-jo 12-chome Teine-ku, Sapporo, 006-8555, Japan
| | - Junichi Nakamura
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Takahiro Sato
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
- Division of Respiratory and Cardiovascular Innovative Research, Faculty of Medicine, Hokkaido University, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Ichizo Tsujino
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
- Division of Respiratory and Cardiovascular Innovative Research, Faculty of Medicine, Hokkaido University, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
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16
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Gowda SH, Patel N. "Heart of the Matter": Cardiac Dysfunction in Congenital Diaphragmatic Hernia. Am J Perinatol 2024; 41:e1709-e1716. [PMID: 37011900 DOI: 10.1055/a-2067-7925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Despite advances in caring for neonates with congenital diaphragmatic hernia (CDH), mortality and morbidity continues to be high. Additionally, the pathophysiology of cardiac dysfunction in this condition is poorly understood. Postnatal cardiac dysfunction in neonates with CDH may be multifactorial with origins in fetal life. Mechanical obstruction, competition from herniated abdominal organs into thoracic cavity combined with redirection of ductus venosus flow away from patent foramen ovale leading to smaller left-sided structures may be a contributing factor. This shunting decreases left atrial and left ventricular blood volume, which may result in altered micro- and macrovascular aberrations affecting cardiac development in the prenatal period. Direct mass effect from herniated intra-abdominal contents restricting cardiac growth and/or reduced left ventricular preload may contribute independently to left ventricular dysfunction in the absence of right ventricular dysfunction and or pulmonary hypertension. With variable clinical phenotypes of cardiac dysfunction, pulmonary hypertension, and respiratory failure in patients with CDH, there is increased need for individualized diagnosis and tailored therapy. Routine use of therapy such as inhaled nitric oxide and sildenafil that induces significant pulmonary vasodilation may be detrimental in left ventricle dysfunction, whereas in a patient with pure right ventricle dysfunction, they may be beneficial. Targeted functional echocardiography serves as a real-time tool for defining the pathophysiology and aids optimization of vasoactive therapy in affected neonates. KEY POINTS: · Cardiac dysfunction in neonates with CDH is multifactorial.. · Postnatal cardiac dysfunction in patients with CDH has its origins in fetal life.. · Right ventricular dysfunction contributes to systemic hypotension.. · Left ventricular dysfunction contributes to systemic hypotension.. · Supportive therapy should be tailored to clinical phenotype..
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MESH Headings
- Humans
- Hernias, Diaphragmatic, Congenital/complications
- Hernias, Diaphragmatic, Congenital/physiopathology
- Infant, Newborn
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/physiopathology
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Dysfunction, Right/etiology
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/diagnostic imaging
- Echocardiography
- Nitric Oxide
- Hernia, Diaphragmatic/complications
- Hernia, Diaphragmatic/physiopathology
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Affiliation(s)
- Sharada H Gowda
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
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17
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Rouleau SG, Casey SD, Kabrhel C, Vinson DR, Long B. Management of high-risk pulmonary embolism in the emergency department: A narrative review. Am J Emerg Med 2024; 79:1-11. [PMID: 38330877 DOI: 10.1016/j.ajem.2024.01.039] [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: 11/11/2023] [Revised: 12/22/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE. OBJECTIVE This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations. DISCUSSION High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions. CONCLUSIONS Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies.
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Affiliation(s)
- Samuel G Rouleau
- Department of Emergency Medicine, UC Davis Health, University of California, Davis, Sacramento, CA, United States of America.
| | - Scott D Casey
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, CA, United States of America.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - David R Vinson
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
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18
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Lopez MP, Applefeld W, Miller PE, Elliott A, Bennett C, Lee B, Barnett C, Solomon MA, Corradi F, Sionis A, Mireles-Cabodevila E, Tavazzi G, Alviar CL. Complex Heart-Lung Ventilator Emergencies in the CICU. Cardiol Clin 2024; 42:253-271. [PMID: 38631793 DOI: 10.1016/j.ccl.2024.02.010] [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: 04/19/2024]
Abstract
This review aims to enhance the comprehension and management of cardiopulmonary interactions in critically ill patients with cardiovascular disease undergoing mechanical ventilation. Highlighting the significance of maintaining a delicate balance, this article emphasizes the crucial role of adjusting ventilation parameters based on both invasive and noninvasive monitoring. It provides recommendations for the induction and liberation from mechanical ventilation. Special attention is given to the identification of auto-PEEP (positive end-expiratory pressure) and other situations that may impact hemodynamics and patients' outcomes.
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Affiliation(s)
- Mireia Padilla Lopez
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Willard Applefeld
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - P. Elliott Miller
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Andrea Elliott
- Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Courtney Bennett
- Heart and Vascular Institute, Leigh Valley Health Network, Allentown, PA, USA
| | - Burton Lee
- Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, MA, USA
| | - Christopher Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Michael A Solomon
- Clinical Center and Cardiology Branch, Critical Care Medicine Department, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MA, USA
| | - Francesco Corradi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Sionis
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eduardo Mireles-Cabodevila
- Respiratory Institute, Cleveland Clinic, Ohio and the Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Guido Tavazzi
- Department of Critical Care Medicine, Intensive Care Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carlos L Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University School of Medicine, USA.
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19
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Crosara S, Fidanzio F, Oricco S, Dondi F, Mazzoldi C, Monari E, Romito G, Sabetti MC, Troìa R, Quintavalla C. Association between echocardiographic indexes and urinary Neutrophil Gelatinase-Associated Lipocalin (uNGAL) in dogs with myxomatous mitral valve disease. Res Vet Sci 2024; 171:105211. [PMID: 38458044 DOI: 10.1016/j.rvsc.2024.105211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 02/24/2024] [Accepted: 03/03/2024] [Indexed: 03/10/2024]
Abstract
Neutrophil gelatinase-associated lipocalin (NGAL) is a biomarker of tubular damage, and its elevation has been described in human and canine cardiorenal syndrome. The aim was to evaluate the association between echocardiographic indexes and urine NGAL (uNGAL) and uNGAL normalized to urine creatinine (uNGALC) in dogs with MMVD. This is a multicentric prospective cross-sectional study. A total of 77 dogs with MMVD at different ACVIM stages were included. All dogs underwent echocardiography, serum chemistry, and urinalysis. Echocardiographic data analyzed were shortening fraction (SF), left ventricular diastolic (LVIDDn) and systolic (LVIDSn) diameters normalized for body weight, left atrium to aortic root ratio (LA/Ao), maximal (LAVMax) and minimal (LAVMin) left atrial volumes, LA stroke volume (LASV), early diastolic mitral peak velocity (EVmax), EVmax to tissue Doppler E' wave (E/E'), aortic (VTIAo) and mitralic (VTIMit) velocity time integrals and their ratio (VTIMit/VTIAo), and tricuspid regurgitation velocity (TRVmax). In the univariate analysis LASV, TRVmax, LAVMax, LVIDDn, and VTIMit/VTIAo were independent predictors of increased uNGAL and uNGALC; however, only LASV [(OR: 1.96, 95% CI: 1.16 to 3.31) P = 0.01 for NGAL, and (OR: 2.79, 95% CI: 1.50 to 5.17) P < 0.001 for NGALC] and TRVmax [(OR: 1.73, 95% CI: 1.20-2.51) P = 0.002 for NGAL, and (OR: 1.50, 95% CI: 10.07-2.10) P = 0.015 for NGALC] remained statistically significant in the multivariable analysis. Based on our results, LASV and TRVmax are associated with increased uNGAL and uNGALC. These parameters might detect dogs with MMVD at higher risk of developing kidney damage.
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Affiliation(s)
- Serena Crosara
- Department of Veterinary Sciences, University of Parma, Strada del Taglio 10, Parma, Italy
| | - Francesca Fidanzio
- Department of Veterinary Sciences, University of Parma, Strada del Taglio 10, Parma, Italy
| | - Stefano Oricco
- Department of Veterinary Sciences, University of Parma, Strada del Taglio 10, Parma, Italy; Centro Veterinario Imperiese, Via Armelio 10, Imperia, Italy.
| | - Francesco Dondi
- Department of Veterinary Medical Sciences, Alma Mater Studiorum - University of Bologna, Via Tolara di Sopra 50, Ozzano dell'Emilia, Bologna, Italy
| | - Chiara Mazzoldi
- Department of Veterinary Medical Sciences, Alma Mater Studiorum - University of Bologna, Via Tolara di Sopra 50, Ozzano dell'Emilia, Bologna, Italy
| | - Erika Monari
- Department of Veterinary Medical Sciences, Alma Mater Studiorum - University of Bologna, Via Tolara di Sopra 50, Ozzano dell'Emilia, Bologna, Italy
| | - Giovanni Romito
- Department of Veterinary Medical Sciences, Alma Mater Studiorum - University of Bologna, Via Tolara di Sopra 50, Ozzano dell'Emilia, Bologna, Italy
| | - Maria Chiara Sabetti
- Department of Veterinary Sciences, University of Parma, Strada del Taglio 10, Parma, Italy
| | - Roberta Troìa
- Department of Veterinary Medical Sciences, Alma Mater Studiorum - University of Bologna, Via Tolara di Sopra 50, Ozzano dell'Emilia, Bologna, Italy
| | - Cecilia Quintavalla
- Department of Veterinary Sciences, University of Parma, Strada del Taglio 10, Parma, Italy
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Loosen G, Taboada D, Ortmann E, Martinez G. How Would I Treat My Own Chronic Thromboembolic Pulmonary Hypertension in the Perioperative Period? J Cardiothorac Vasc Anesth 2024; 38:884-894. [PMID: 37716891 DOI: 10.1053/j.jvca.2023.07.014] [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: 02/20/2023] [Revised: 07/04/2023] [Accepted: 07/14/2023] [Indexed: 09/18/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) results from an incomplete resolution of acute pulmonary embolism, leading to occlusive organized thrombi, vascular remodeling, and associated microvasculopathy with pulmonary hypertension (PH). A definitive CTEPH diagnosis requires PH confirmation by right-heart catheterization and evidence of chronic thromboembolic pulmonary disease on imaging studies. Surgical removal of the organized fibrotic material by pulmonary endarterectomy (PEA) under deep hypothermic circulatory arrest represents the treatment of choice. One-third of patients with CTEPH are not deemed suitable for surgical treatment, and medical therapy or interventional balloon pulmonary angioplasty presents alternative treatment options. Pulmonary endarterectomy in patients with technically operable disease significantly improves symptoms, functional capacity, hemodynamics, and quality of life. Perioperative mortality is <2.5% in expert centers where a CTEPH multidisciplinary team optimizes patient selection and ensures the best preoperative optimization according to individualized risk assessment. Despite adequate pulmonary artery clearance, patients might be prone to perioperative complications, such as right ventricular maladaptation, airway bleeding, or pulmonary reperfusion injury. These complications can be treated conventionally, but extracorporeal membrane oxygenation has been included in their management recently. Patients with residual PH post-PEA should be considered for medical or percutaneous interventional therapy.
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Affiliation(s)
- Gregor Loosen
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Dolores Taboada
- Pulmonary Vascular Diseases Unit, Cambridge National Pulmonary Hypertension Service, Royal Papworth Hospital NHS, Department of Cardiothoracic Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Erik Ortmann
- Department of Anesthesiology, Schuechtermann-Heart-Centre, Bad Rothenfelde, Germany
| | - Guillermo Martinez
- Pulmonary Vascular Diseases Unit, Cambridge National Pulmonary Hypertension Service, Royal Papworth Hospital NHS, Department of Cardiothoracic Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom.
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21
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Tian F, Weng H, Liu A, Liu W, Zhang B, Wang Y, Cheng Y, Cheng S, Fulati Z, Zhou N, Kong D, Pan C, Su Y, Xu N, Chen H, Shu X. Effect of left bundle branch pacing on right ventricular function: A 3-dimensional echocardiography study. Heart Rhythm 2024; 21:445-453. [PMID: 38147906 DOI: 10.1016/j.hrthm.2023.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/16/2023] [Accepted: 12/20/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND The effect of left bundle branch pacing (LBBP) on right ventricular (RV) function is not well known, and there is conflicting evidence regarding whether cardiac resynchronization therapy improves RV function. OBJECTIVES The study aimed to investigate the effect of LBBP on RV function and to evaluate the response of RV dysfunction (RVD) to LBBP. METHODS Sixty-five LBBP candidates were prospectively included in the study and underwent echocardiography at baseline and 6-month follow-up. LBBP response was left ventricular (LV) reverse remodeling, defined as a reduction in LV end-systolic volume of ≥15% at follow-up. RESULTS Patients were assigned to 2 subgroups on the basis of 3-dimensional echocardiography-derived RV ejection fraction (EF) before LBBP implantation: 30 patients (46%) in the no RVD group and 35 patients (54%) in the RVD group. The RVD group was characterized by higher N-terminal pro-brain natriuretic peptide levels, New York Heart Association functional class, and larger LV/RV size. LBBP induced a significant reduction in QRS duration, LV size, and improvement in LVEF and mechanical dyssynchrony in both the no RVD and RVD groups, and a significant improvement in RV volumes and RVEF in the RVD group (all P<.01). LBBP resulted in a similar percentage reduction in QRS duration, LV dimensions, LV volumes, and percentage improvement in LVEF in RVD and no RVD groups (all P>.05). LV reverse remodeling (29 of 35 patients vs 27 of 30 patients; P = .323) in the RVD group was similar to that in the no RVD group after LBBP. CONCLUSION LBBP induces excellent electrical and mechanical resynchronization, with a significant improvement in RV volumes and function. RVD did not diminish the beneficial effects on LV reverse remodeling after LBBP.
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Affiliation(s)
- Fangyan Tian
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Shanghai, China; Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China; Department of Ultrasound Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Haobo Weng
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Shanghai, China; Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China
| | - Ao Liu
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Shanghai, China; Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China
| | - Wen Liu
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Bei Zhang
- Department of Ultrasound Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Yanan Wang
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Yufei Cheng
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Shan Cheng
- Department of Ultrasound Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Zibire Fulati
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Nianwei Zhou
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Dehong Kong
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Cuizhen Pan
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Yangang Su
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China
| | - Nuo Xu
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Shanghai, China; Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China.
| | - Haiyan Chen
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Shanghai, China; Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China.
| | - Xianhong Shu
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Shanghai, China; Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, China.
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Kresoja KP, Rosch S, Schöber AR, Fengler K, Schlotter F, Bombace S, Sagmeister P, von Roeder M, Kister T, Gutberlet M, Thiele H, Rommel KP, Lurz P. Implications of tricuspid regurgitation and right ventricular volume overload in patients with heart failure with preserved ejection fraction. Eur J Heart Fail 2024; 26:1025-1035. [PMID: 38462987 DOI: 10.1002/ejhf.3195] [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: 01/04/2024] [Revised: 02/11/2024] [Accepted: 02/24/2024] [Indexed: 03/12/2024] Open
Abstract
AIMS The aim of this study was to assess the pathophysiological implications of severe tricuspid regurgitation (TR) in patients with heart failure with preserved ejection fraction (HFpEF) by using tricuspid transcatheter edge-to-edge repair (T-TEER) as a model of right ventricular (RV) volume overload relief. METHODS AND RESULTS This prospective interventional single arm trial (NCT04782908) included patients with invasively diagnosed HFpEF. The following parameters were prospectively assessed before and after T-TEER: left ventricular (LV) diastolic properties by invasive pressure-volume loop recordings; biventricular time-volume curves and function as well as septal curvature by cardiac magnetic resonance imaging; strain analyses for timing of septal motion. Overall, 20 patients (median age 78, interquartile range [IQR] 72-83 years, 65% female) were included. T-TEER reduced TR by a median of 2 (of 5) grades (IQR 2-1). T-TEER increased LV stroke volume and LV end-diastolic volume (LVEDV) (p < 0.001), without increasing LV end-diastolic pressure (LVEDP) (p = 0.094), consequently diastolic function improved with a reduction in LVEDP/LVEDV (p = 0.001) and a rightward shift of the end-diastolic pressure-volume relationship. The increase in LVEDV correlated with a decrease in RV end-diastolic volume (p < 0.001) and LV transmural pressure increased (p = 0.028). Secondary to a decrease in early RV filling, improvements in early LV filling were observed, correlating with an alleviation of leftwards bowing of the septum (p < 0.01, respectively). CONCLUSION Diastolic LV properties in patients with HFpEF and severe TR are importantly determined by ventricular interaction in the setting of RV volume overload. T-TEER reduces RV volume overload and improves biventricular interaction and physiology.
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Affiliation(s)
- Karl-Patrik Kresoja
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
- Department of Cardiology, Universitätsmedizin Johannes Gutenberg-University, Mainz, Germany
| | - Sebastian Rosch
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
- Department of Cardiology, Universitätsmedizin Johannes Gutenberg-University, Mainz, Germany
| | - Anne Rebecca Schöber
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
- Department of Cardiology, Universitätsmedizin Johannes Gutenberg-University, Mainz, Germany
| | - Karl Fengler
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Florian Schlotter
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Sara Bombace
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
- Department of Cardiology, Universitätsmedizin Johannes Gutenberg-University, Mainz, Germany
| | - Paula Sagmeister
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Maximilian von Roeder
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Tobias Kister
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Matthias Gutberlet
- Institute of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Karl-Philipp Rommel
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Philipp Lurz
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
- Department of Cardiology, Universitätsmedizin Johannes Gutenberg-University, Mainz, Germany
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Sljivic A, Kleut MP, Celic V, Neskovic AN, Nesic I, Gazibara T. How Right is the Right Ventricle in Predicting Cardiac Mortality in Cardiac Failure: A 6-year Prospective Cohort Study. J Cardiovasc Echogr 2024; 34:50-56. [PMID: 39086703 PMCID: PMC11288295 DOI: 10.4103/jcecho.jcecho_13_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 03/28/2024] [Accepted: 04/27/2024] [Indexed: 08/02/2024] Open
Abstract
Aim Two-dimensional speckle tracking echocardiography (2D-STE) and three-dimensional echocardiography (3DE) may overcome many limitations of the conventional 2D echocardiography (2DE) in assessing right ventricular (RV) function. We sought to determine whether characteristics of the right atrium and right ventricle as measured by 2D-STE and 3DE are associated with cardiac mortality in patients with ischemic heart failure, over a 6-year follow-up. Materials and Methods The inclusion criteria were ischemic cardiomyopathy with left ventricular ejection fraction of <40% diagnosed using standard 2DE, 2D-STE, and 3DE examination. Patients were followed for 6 years, and cardiac mortality was recorded. Results The study sample comprised a total of 54 participants. During the period of follow-up, 24% (13/54) died. The 2DE models showed that being older, having a higher body mass index (BMI), having higher systolic pulmonary artery pressure (SPAP), and a lower RV global longitudinal strain were associated with cardiac mortality in our cohort after 6-year follow-up. Finally, the 3DE models showed that in addition to being older, having higher BMI, having a higher SPAP baseline, lower baseline 3DE RV stroke volume, and larger 3DE RV end-diastolic volume and 3DE RV end-systolic volume were associated with cardiac mortality over 6-year follow-up. Conclusion This study provides evidence that RV dysfunction as seen on 2D-STE and 3DE could be associated with increased risk of cardiac-related mortality in patients with heart failure over 6 years.
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Affiliation(s)
- Aleksandra Sljivic
- Department of Cardiology, University Clinical Hospital Center “Dr. Dragisa Misovic-Dedinje”, Belgrade, Serbia
| | - Milena Pavlovic Kleut
- Department of Cardiology, University Clinical Hospital Center “Dr. Dragisa Misovic-Dedinje”, Belgrade, Serbia
| | - Vera Celic
- Department of Cardiology, University Clinical Hospital Center “Dr. Dragisa Misovic-Dedinje”, Belgrade, Serbia
- Department of Internal Medicine, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Aleksandar N. Neskovic
- Department of Internal Medicine, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Cardiology, Faculty of Medicine, Clinical Hospital Zemun, University of Belgrade, Belgrade, Serbia
| | - Ivan Nesic
- Department of Cardiac Surgery, Faculty of Medicine, Cardiovascular Institute Dedinje, Belgrade, Serbia
- Department of Surgery, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Tatjana Gazibara
- Department of Epidemiology, Faculty of Medicine, Institute of Epidemiology, University of Belgrade, Belgrade, Serbia
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Chaudhari T, Schmidt Sotomayor N, Maheshwari R. Diagnosis, management and long term cardiovascular outcomes of phenotypic profiles in pulmonary hypertension associated with congenital diaphragmatic hernia. Front Pediatr 2024; 12:1356157. [PMID: 38590769 PMCID: PMC10999638 DOI: 10.3389/fped.2024.1356157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/26/2024] [Indexed: 04/10/2024] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a developmental defect of the diaphragm resulting in herniation of viscera into the chest. This condition is characterized by pulmonary hypoplasia, pulmonary hypertension (PH) and cardiac ventricular dysfunction. PH is a key component of the pathophysiology of CDH in neonates and contributes to morbidity and mortality. Traditionally, PH associated with CDH (CDH-PH) is thought to be secondary to increased pulmonary arterial resistance and vasoreactivity resulting from pulmonary hypoplasia. Additionally, there is increasing recognition of associated left ventricular hypoplasia, dysfunction and elevated end diastolic pressure resulting in pulmonary venous hypertension in infants with CDH. Thus, hemodynamic management of these infants is complex and cautious use of pulmonary vasodilators such as inhaled nitric oxide (iNO) is warranted. We aim to provide an overview of different phenotypic profiles of CDH associated PH and potential management options based on current evidence and pathophysiology.
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Affiliation(s)
- Tejasvi Chaudhari
- Department of Neonatology, The Canberra Hospital, Canberra, ACT, Australia
- Australian National University Medical School, Australian National University, Canberra, ACT, Australia
| | - Nadia Schmidt Sotomayor
- Department of Neonatology, The Canberra Hospital, Canberra, ACT, Australia
- Australian National University Medical School, Australian National University, Canberra, ACT, Australia
| | - Rajesh Maheshwari
- Department of Neonatology, Westmead Hospital, Sydney, NSW, Australia
- The Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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25
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Agoston-Coldea L, Negru A. Myocardial fibrosis in right heart dysfunction. Adv Clin Chem 2024; 119:71-116. [PMID: 38514212 DOI: 10.1016/bs.acc.2024.02.005] [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: 03/23/2024]
Abstract
Cardiac fibrosis, associated with right heart dysfunction, results in significant morbidity and mortality. Stimulated by various cellular and humoral stimuli, cardiac fibroblasts, macrophages, CD4+ and CD8+ T cells, mast and endothelial cells promote fibrogenesis directly and indirectly by synthesizing numerous profibrotic factors. Several systems, including the transforming growth factor-beta and the renin-angiotensin system, produce type I and III collagen, fibronectin and α-smooth muscle actin, thus modifying the extracellular matrix. Although magnetic resonance imaging with gadolinium enhancement remains the gold standard, the use of circulating biomarkers represents an inexpensive and attractive means to facilitate detection and monitor cardiovascular fibrosis. This review explores the use of protein and nucleic acid (miRNAs) markers to better understand underlying pathophysiology as well as their role in the development of therapeutics to inhibit and potentially reverse cardiac fibrosis.
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Affiliation(s)
- Lucia Agoston-Coldea
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
| | - Andra Negru
- Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Chen H, Huang L, Xing B, Gao Y, Zhang J, Zhang B. Prognostic value of right ventricular free wall strain in patients with sepsis. Front Cardiovasc Med 2024; 11:1334759. [PMID: 38450378 PMCID: PMC10915020 DOI: 10.3389/fcvm.2024.1334759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/05/2024] [Indexed: 03/08/2024] Open
Abstract
Background Right ventricular systolic dysfunction (RVSD) in patients with sepsis is an area of growing interest, but its prognostic significance remains unclear and additional tools are needed to improve our understanding. Right ventricular free wall strain (RV-FWS) is a relatively new parameter to assess RV function. This study aimed to investigate the potential correlation between impaired RV-FWS and prognostic outcomes in patients with sepsis. Methods We prospectively assessed right ventricular function in patients with sepsis within the initial 24 h of their hospital admission. RV-FWS, right ventricular global strain (RV-GS), fractional area change (FAC), and tricuspid annular plane systolic excursion (TAPSE) were examined. RVSD was defined as impaired RV-FWS. Moreover, the association between RVSD and 30-day mortality rate was assessed. Results This study included 89 patients. Among them, 27 (30.3%) succumbed to their illness within 30 days. The nonsurviving patients demonstrated significantly lower absolute RV-FWS (-19.7% ± 2.4% vs. -21.1% ± 2.1%, P = 0.008) and RV-GS (-17.7% ± 1.2% vs. -18.4% ± 1.4%, P = 0.032) values than the surviving patients. However, TAPSE and FAC values were not significantly different between the two groups. The optimal cutoff values for RV-FWS, RV-GS, FAC, and TAPSE were -19.0%, -17.9%, 36.5%, and 1.55 cm, respectively. Kaplan-Meier survival curves revealed that patients with impaired RV-FWS and RV-GS demonstrated lower 30-day survival rates, and the predictive performance of RV-FWS (hazard ratio [HR]: 3.97, 95% confidence interval [CI]: 1.85-8.51, P < 0.001) was slightly higher than FAC and TAPSE. However, multivariable Cox regression analysis revealed no association between impaired RV-FWS and mortality outcomes (HR: 1.85, 95% CI: 0.56-6.14, P = 0.316). Conclusions Impaired RV-FWS is not associated with short-term mortality outcomes, and RV strain imaging is of limited value in assessing the prognosis of sepsis.
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Affiliation(s)
- Hongmin Chen
- Department of Ultrasound, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People’s Hospital, Yichang, China
| | - Lei Huang
- Department of Critical Care Medicine, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People’s Hospital, Yichang, China
| | - Boyuan Xing
- Department of Ultrasound, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People’s Hospital, Yichang, China
| | - Yang Gao
- Department of Ultrasound, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People’s Hospital, Yichang, China
| | - Jie Zhang
- Department of Ultrasound, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People’s Hospital, Yichang, China
| | - Bingyi Zhang
- Department of Ultrasound, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People’s Hospital, Yichang, China
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27
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Inno G, Itatani K, Nishiya K, Takahashi Y, Shibata T. Staged therapeutic surgery for progressive pulmonary regurgitation and pacemaker induced cardiomyopathy after the tetralogy of fallot repair. J Cardiothorac Surg 2024; 19:98. [PMID: 38365717 PMCID: PMC10873977 DOI: 10.1186/s13019-024-02585-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/30/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Recently, improvements in the repair of tetralogy of Fallot have increased the need for reoperation in adulthood, and it's not rare that these reoperation candidates suffer from biventricular failure. However, there are no firm treatment guidelines, and each country, and even each facility, treats each case individually. CASE PRESENTATION We report the successful staged treatment of pulmonary regurgitation and pacemaker-induced cardiomyopathy with biventricular failure in adulthood in a case of complete atrioventricular block after tetralogy of Fallot repair in childhood. We planned a staged therapeutic strategy with preoperative left ventricular volume reduction with medication, following surgical pulmonary valve replacement concomitant epicardial lead implantation on the lateral basal wall, placed just beneath the generator pocket through 3rd intercostal space. in addition to postoperative intervention with a defibrillator to adjust cardiac resynchronization therapy, resulted in improvement of symptoms. CONCLUSION In a patient with biventricular failure after TOF repair, a staged treatment strategy involving medication, PVR, and CRT with a combination of epicardial and intravenous leads could be a useful treatment worth trying before heart transplantation.
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Affiliation(s)
- Goki Inno
- Department of Cardiovascular Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Keiichi Itatani
- Department of Cardiovascular Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-Ku, Osaka, 545-8585, Japan.
- Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan.
| | - Kenta Nishiya
- Department of Cardiovascular Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Yosuke Takahashi
- Department of Cardiovascular Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-Ku, Osaka, 545-8585, Japan
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Mereles D, Rudolph J, Greiner S, Aurich M, Frey N, Katus HA, Bärtsch P, Dehnert C. Acute changes in cardiac dimensions, function, and longitudinal mechanics in healthy individuals with and without high-altitude induced pulmonary hypertension at 4559 m. Echocardiography 2024; 41:e15786. [PMID: 38400544 DOI: 10.1111/echo.15786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND High-altitude pulmonary hypertension (HAPH) has a prevalence of approximately 10%. Changes in cardiac morphology and function at high altitude, compared to a population that does not develop HAPH are scarce. METHODS Four hundred twenty-one subjects were screened in a hypoxic chamber inspiring a FiO2 = 12% for 2 h. In 33 subjects an exaggerated increase in systolic pulmonary artery pressure (sPAP) could be confirmed in two independent measurements. Twenty nine of these, and further 24 matched subjects without sPAP increase were examined at 4559 m by Doppler echocardiography including global longitudinal strain (GLS). RESULTS SPAP increase was higher in HAPH subjects (∆ = 10.2 vs. ∆ = 32.0 mm Hg, p < .001). LV eccentricity index (∆ = .15 vs. ∆ = .31, p = .009) increased more in HAPH. D-shaped LV (0 [0%] vs. 30 [93.8%], p = .00001) could be observed only in the HAPH group, and only in those with a sPAP ≥50 mm Hg. LV-EF (∆ = 4.5 vs. ∆ = 6.7%, p = .24) increased in both groups. LV-GLS (∆ = 1.2 vs. ∆ = 1.1 -%, p = .60) increased slightly. RV end-diastolic (∆ = 2.20 vs. ∆ = 2.7 cm2 , p = .36) and end-systolic area (∆ = 2.1 vs. ∆ = 2.7 cm2 , p = .39), as well as RA end-systolic area index (∆ = -.9 vs. ∆ = .3 cm2 /m2 , p = .01) increased, RV-FAC (∆ = -2.9 vs. ∆ = -4.7%, p = .43) decreased, this was more pronounced in HAPH, RV-GLS (∆ = 1.6 vs. ∆ = -.7 -%, p = .17) showed marginal changes. CONCLUSIONS LV and LA dimensions decrease and left ventricular function increases at high-altitude in subjects with and without HAPH. RV and RA dimensions increase, and RV longitudinal strain increases or remains unchanged in subjects with HAPH. Changes are negligible in those without HAPH.
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Affiliation(s)
- Derliz Mereles
- Internal Medicine III, Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jens Rudolph
- Internal Medicine III, Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sebastian Greiner
- Internal Medicine III, Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Aurich
- Internal Medicine III, Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Norbert Frey
- Internal Medicine III, Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Internal Medicine III, Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Bärtsch
- Internal Medicine VII, Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Dehnert
- Internal Medicine VII, Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
- University Centre for Prevention and Sports Medicine, University Clinic Balgrist, University of Zurich, Zurich, Switzerland
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van de Veerdonk MC, Roosma L, Trip P, Gopalan D, Vonk Noordegraaf A, Dorfmüller P, Nossent EJ. Clinical-imaging-pathological correlation in pulmonary hypertension associated with left heart disease. Eur Respir Rev 2024; 33:230144. [PMID: 38417969 PMCID: PMC10900069 DOI: 10.1183/16000617.0144-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/25/2023] [Indexed: 03/01/2024] Open
Abstract
Pulmonary hypertension (PH) is highly prevalent in patients with left heart disease (LHD) and negatively impacts prognosis. The most common causes of PH associated with LHD (PH-LHD) are left heart failure and valvular heart disease. In LHD, passive backward transmission of increased left-sided filling pressures leads to isolated post-capillary PH. Additional pulmonary vasoconstriction and remodelling lead to a higher vascular load and combined pre- and post-capillary PH. The increased afterload leads to right ventricular dysfunction and failure. Multimodality imaging of the heart plays a central role in the diagnostic work-up and follow-up of patients with PH-LHD. Echocardiography provides information about the estimated pulmonary artery pressure, morphology and function of the left and right side of the heart, and valvular abnormalities. Cardiac magnetic resonance imaging is the gold standard for volumetric measurements and provides myocardial tissue characterisation. Computed tomography of the thorax may show general features of PH and/or LHD and is helpful in excluding other PH causes. Histopathology reveals a spectrum of pre- and post-capillary vasculopathy, including intimal fibrosis, media smooth muscle cell hyperplasia, adventitial fibrosis and capillary congestion. In this paper, we provide an overview of clinical, imaging and histopathological findings in PH-LHD based on three clinical cases.
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Affiliation(s)
- Marielle C van de Veerdonk
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Lize Roosma
- Department of Pulmonary Diseases, Amsterdam University Medical Centers, Free University, Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Pia Trip
- Department of Pulmonary Diseases, Amsterdam University Medical Centers, Free University, Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Deepa Gopalan
- Department of Radiology, Imperial College Hospital NHS Trust, London, UK
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Diseases, Amsterdam University Medical Centers, Free University, Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Peter Dorfmüller
- Department of Pathology, University Hospital Giessen and Marburg (UKGM), German Centre for Lung Research (DZL) and Institute for Lung Health (ILH), Giessen, Germany
| | - Esther J Nossent
- Department of Pulmonary Diseases, Amsterdam University Medical Centers, Free University, Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
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30
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Benza RL, Grünig E, Sandner P, Stasch JP, Simonneau G. The nitric oxide-soluble guanylate cyclase-cGMP pathway in pulmonary hypertension: from PDE5 to soluble guanylate cyclase. Eur Respir Rev 2024; 33:230183. [PMID: 38508664 PMCID: PMC10957071 DOI: 10.1183/16000617.0183-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/18/2024] [Indexed: 03/22/2024] Open
Abstract
The nitric oxide (NO)-soluble guanylate cyclase (sGC)-cyclic guanosine monophosphate (cGMP) pathway plays a key role in the pathogenesis of pulmonary hypertension (PH). Targeted treatments include phosphodiesterase type 5 inhibitors (PDE5i) and sGC stimulators. The sGC stimulator riociguat is approved for the treatment of pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). sGC stimulators have a dual mechanism of action, enhancing the sGC response to endogenous NO and directly stimulating sGC, independent of NO. This increase in cGMP production via a dual mechanism differs from PDE5i, which protects cGMP from degradation by PDE5, rather than increasing its production. sGC stimulators may therefore have the potential to increase cGMP levels under conditions of NO depletion that could limit the effectiveness of PDE5i. Such differences in mode of action between sGC stimulators and PDE5i could lead to differences in treatment efficacy between the classes. In addition to vascular effects, sGC stimulators have the potential to reduce inflammation, angiogenesis, fibrosis and right ventricular hypertrophy and remodelling. In this review we describe the evolution of treatments targeting the NO-sGC-cGMP pathway, with a focus on PH.
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Affiliation(s)
| | - Ekkehard Grünig
- Pulmonary Hypertension Unit, Thoraxklinik at Heidelberg University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Sandner
- Bayer AG, Wuppertal, Germany
- Institute of Pharmacology, Hannover Medical School, Hannover, Germany
| | - Johannes-Peter Stasch
- Bayer AG, Wuppertal, Germany
- Institute of Pharmacy, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Gérald Simonneau
- Centre de Référence de l'Hypertension Pulmonaire Sévère, CHU Kremlin Bicêtre, Kremlin Bicêtre, France
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31
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Hopman LHGA, Zweerink A, van de Veerdonk MC, van der Lingen ALCJ, Huntelaar MJ, Robbers LFHJ, van Rossum AC, Götte MJW, van Halm VP, Allaart CP. Post-implantation CMR imaging to study biventricular pacing effects on the right ventricle in left bundle branch block patients. Pacing Clin Electrophysiol 2024; 47:121-123. [PMID: 38055567 DOI: 10.1111/pace.14900] [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: 10/19/2023] [Revised: 11/07/2023] [Accepted: 11/25/2023] [Indexed: 12/08/2023]
Abstract
Cardiac resynchronization therapy (CRT) is an established treatment for heart failure patients with left ventricular dysfunction and a left bundle branch block. However, its impact on right ventricular (RV) function remains uncertain. This cardiac magnetic resonance imaging study found that CRT did not improve RV volumes and function, and CRT-off during follow-up had an immediate detrimental effect on the RV, which may suggest potential unfavorable RV remodeling with RV pacing during CRT.
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Affiliation(s)
| | - Alwin Zweerink
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
| | | | | | | | | | | | - Marco J W Götte
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Vokko P van Halm
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
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32
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Behnia M, Sietsema KE. Utility of Cardiopulmonary Exercise Testing in Chronic Obstructive Pulmonary Disease: A Review. Int J Chron Obstruct Pulmon Dis 2023; 18:2895-2910. [PMID: 38089541 PMCID: PMC10710955 DOI: 10.2147/copd.s432841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/17/2023] [Indexed: 12/18/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a disease defined by airflow obstruction with a high morbidity and mortality and significant economic burden. Although pulmonary function testing is the cornerstone in diagnosis of COPD, it cannot fully characterize disease severity or cause of dyspnea because of disease heterogeneity and variable related and comorbid conditions affecting cardiac, vascular, and musculoskeletal systems. Cardiopulmonary exercise testing (CPET) is a valuable tool for assessing physical function in a wide range of clinical conditions, including COPD. Familiarity with measurements made during CPET and its potential to aid in clinical decision-making related to COPD can thus be useful to clinicians caring for this population. This review highlights pulmonary and extrapulmonary impairments that can contribute to exercise limitation in COPD. Key elements of CPET are identified with an emphasis on measurements most relevant to COPD. Finally, clinical applications of CPET demonstrated to be of value in the COPD setting are identified. These include quantifying functional capacity, differentiating among potential causes of symptoms and limitation, prognostication and risk assessment for operative procedures, and guiding exercise prescription.
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Affiliation(s)
- Mehrdad Behnia
- Pulmonary and Critical Care, University of Central Florida, Orlando, FL, USA
| | - Kathy E Sietsema
- The Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, CA, USA
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33
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Jenkins DP, Martinez G, Salaunkey K, Reddy SA, Pepke-Zaba J. Perioperative Management in Pulmonary Endarterectomy. Semin Respir Crit Care Med 2023; 44:851-865. [PMID: 37487525 DOI: 10.1055/s-0043-1770123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH), provided lesions are proximal enough in the pulmonary vasculature to be surgically accessible and the patient is well enough to benefit from the operation in the longer term. It is a major cardiothoracic operation, requiring specialized techniques and instruments developed over several decades to access and dissect out the intra-arterial fibrotic material. While in-hospital operative mortality is low (<5%), particularly in high-volume centers, careful perioperative management in the operating theater and intensive care is mandatory to balance ventricular performance, fluid balance, ventilation, and coagulation to avoid or treat complications. Reperfusion pulmonary edema, airway hemorrhage, and right ventricular failure are the most problematic complications, often requiring the use of extracorporeal membrane oxygenation to bridge to recovery. Successful PEA has been shown to improve both morbidity and mortality in large registries, with survival >70% at 10 years. For patients not suitable for PEA or with residual PH after PEA, balloon pulmonary angioplasty and/or PH medical therapy may prove beneficial. Here, we describe the indications for PEA, specific surgical and perioperative strategies, postoperative monitoring and management, and approaches for managing residual PH in the long term.
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Affiliation(s)
- David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Guillermo Martinez
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Kiran Salaunkey
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - S Ashwin Reddy
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
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34
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Savale L, Kularatne M, Roche A, Pichon J, Baron A, Boucly A, Sitbon O, Humbert M. Management of Acutely Decompensated Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:762-770. [PMID: 37369216 DOI: 10.1055/s-0043-1770119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Pulmonary arterial hypertension is a severe life-threatening condition associated with increased pulmonary vascular resistance and resulting right heart dysfunction. Admission to intensive care unit with acutely decompensated right heart failure is a significant negative prognostic event with a high risk of multisystem organ dysfunction and death. Presentations are heterogenous and may combine signs of both diastolic and systolic dysfunction complicating management. Renal dysfunction is often present, but other organ systems can be involved resulting in findings such as acute hepatic dysfunction or bowel wall congestion and ischemia. The goals of therapy are to rapidly reverse ventriculo-arterial decoupling and reduce right ventricular afterload to prevent progression to refractory or irreversible right heart failure. Triggering events must be investigated for and addressed urgently if identified. Volume status management is critical and both noninvasive and invasive testing can aid in prognostication and guide management, including the use of inotropes and vasopressors. In cases of refractory right heart dysfunction, consideration of urgent lung transplantation and mechanical circulatory support is necessary. These patients should be managed at expert centers in an intensive care setting with a multidisciplinary team of practitioners experienced in the management of right heart dysfunction given the high short- and long-term mortality resulting from acute decompensated right heart failure.
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Affiliation(s)
- Laurent Savale
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Mithum Kularatne
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Calgary, Canada
| | - Anne Roche
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Jérémie Pichon
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Audrey Baron
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Athenaïs Boucly
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Olivier Sitbon
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Marc Humbert
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
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Gaweda B, Gaddam M, Jaźwiec T, Bush JD, MacDougall B, Widenka K, Timek TA. Papillary muscle approximation in chronic ovine functional tricuspid regurgitation. J Thorac Cardiovasc Surg 2023; 166:e502-e509. [PMID: 37330209 DOI: 10.1016/j.jtcvs.2023.05.039] [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: 02/28/2023] [Revised: 05/18/2023] [Accepted: 05/31/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE Isolated tricuspid ring annuloplasty remains the surgical standard for functional tricuspid regurgitation repair but offers suboptimal results when right ventricular dilation and remodeling along with papillary muscle displacement is present. Addressing subvalvular remodeling with papillary muscle approximation may improve clinical outcomes. METHODS Functional tricuspid regurgitation and biventricular dysfunction were induced in 8 healthy sheep by rapid ventricular pacing (200-240 bpm) for 27 ± 6 days. Subsequently, animals underwent cardiopulmonary bypass for implantation of sonomicrometry crystals on the tricuspid annulus, right ventricle, and papillary muscle tips. Papillary approximation sutures were anchored between anterior-posterior and anterior-septal papillary muscles and externalized through right ventricular free wall to epicardial tourniquets. After weaning from cardiopulmonary bypass, sequential papillary muscle approximations were performed. Simultaneous hemodynamic, sonomicrometry, and echocardiographic data were collected at baseline and after each papillary muscle approximation. RESULTS With rapid pacing, right ventricular fractional area change decreased from 59 ± 6% to 38 ± 8% (P < .001), whereas tricuspid annulus diameter increased from 2.4 ± 0.3 cm to 3.3 ± 0.6 cm (P = .003). Tricuspid regurgitation (0-4+) increased from +0 ± 0 to +3.3 ± 0.7 (P < .001). Both anterior-posterior and anterior-septal papillary muscle approximation significantly reduced functional tricuspid regurgitation from +3.3 ± 0.7 to +2 ± 0.5 and +1.9 ± 0.6, respectively (P < .001). Reduction of tricuspid insufficiency with both subvalvular interventions was associated with decreased distance of the anterior papillary muscle to the annular centroid. CONCLUSIONS Papillary muscle approximations were effective in reducing severe ovine functional tricuspid regurgitation associated with right ventricular dilation and papillary muscle displacement. Further studies are needed to evaluate efficacy of this adjunct to ring annuloplasty in repair of severe functional tricuspid regurgitation.
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Affiliation(s)
- Boguslaw Gaweda
- Division of Cardiothoracic Surgery, Corewell Health, Grand Rapids, Mich; Department of Cardiac Surgery, Faculty of Medicine, Clinical District Hospital No. 2, University of Rzeszow, Rzeszow, Poland
| | - Manikantam Gaddam
- Department of Urology, Stanford University School of Medicine, Stanford, Calif
| | - Tomasz Jaźwiec
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Disease, Medical University of Silesia in Katowice, Zabrze, Poland
| | - Jared D Bush
- Research Department, Corewell Health, Grand Rapids, Mich
| | | | - Kazimierz Widenka
- Department of Cardiac Surgery, Faculty of Medicine, Clinical District Hospital No. 2, University of Rzeszow, Rzeszow, Poland
| | - Tomasz A Timek
- Division of Cardiothoracic Surgery, Corewell Health, Grand Rapids, Mich; College of Human Medicine, Michigan State University, Grand Rapids, Mich.
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da Rosa MC, Vieira PPM, Hattori MH, Coimbra GC, Arrieta R. Transcatheter Treatment for Double-Chambered Right Ventricle in Patient Presenting Severe Chronic Heart Failure. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101211. [PMID: 39131071 PMCID: PMC11307642 DOI: 10.1016/j.jscai.2023.101211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/04/2023] [Accepted: 10/04/2023] [Indexed: 08/13/2024]
Abstract
We report a case involving a 9-year-old girl with severe biventricular dysfunction due to anomalous right ventricle muscle bands. After a thorough discussion, she underwent a transcatheter stenting procedure for the double-chambered right ventricle. During her follow-up, she regained biventricular function, while remaining asymptomatic, resulting in complete recovery.
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Affiliation(s)
- Malu Carmona da Rosa
- Invasive Cardiology Department, Heart Institute of the University of São Paulo (InCor), São Paulo, Brazil
| | - Pedro Paulo M.G. Vieira
- Invasive Cardiology Department, Heart Institute of the University of São Paulo (InCor), São Paulo, Brazil
| | - Mario H. Hattori
- Invasive Cardiology Department, Heart Institute of the University of São Paulo (InCor), São Paulo, Brazil
| | - Germana C. Coimbra
- Invasive Cardiology Department, Heart Institute of the University of São Paulo (InCor), São Paulo, Brazil
| | - Raul Arrieta
- Invasive Cardiology Department, Heart Institute of the University of São Paulo (InCor), São Paulo, Brazil
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37
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Rako ZA, Yogeswaran A, Lakatos BK, Fábián A, Yildiz S, da Rocha BB, Vadász I, Ghofrani HA, Seeger W, Gall H, Kremer NC, Richter MJ, Bauer P, Tedford RJ, Naeije R, Kovács A, Tello K. Clinical and functional relevance of right ventricular contraction patterns in pulmonary hypertension. J Heart Lung Transplant 2023; 42:1518-1528. [PMID: 37451352 DOI: 10.1016/j.healun.2023.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/11/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND The right ventricle has a complex contraction pattern of uncertain clinical relevance. We aimed to assess the relationship between right ventricular (RV) contraction pattern and RV-pulmonary arterial (PA) coupling defined by the gold-standard pressure-volume loop-derived ratio of end-systolic/arterial elastance (Ees/Ea). METHODS Prospectively enrolled patients with suspected or confirmed pulmonary hypertension underwent three-dimensional echocardiography, standard right heart catheterization, and RV conductance catheterization. RV-PA uncoupling was categorized as severe (Ees/Ea < 0.8), moderate (Ees/Ea 0.8-1.29), and none/mild (Ees/Ea ≥ 1.3). Clinical severity was determined from hemodynamics using a truncated version of the 2022 European Society of Cardiology/European Respiratory Society risk stratification scheme. RESULTS Fifty-three patients were included, 23 with no/mild, 24 with moderate, and 6 with severe uncoupling. Longitudinal shortening was decreased in patients with moderate vs no/mild uncoupling (p <0.001) and intermediate vs low hemodynamic risk (p < 0.001), discriminating low risk from intermediate/high risk with an optimal threshold of 18% (sensitivity 80%, specificity 87%). Anteroposterior shortening was impaired in patients with severe vs moderate uncoupling (p = 0.033), low vs intermediate risk (p = 0.018), and high vs intermediate risk (p = 0.010), discriminating high risk from intermediate/low risk with an optimal threshold of 15% (sensitivity 100%, specificity 83%). Left ventricular (LV) end-diastolic volume was decreased in patients with severe uncoupling (p = 0.035 vs no/mild uncoupling). CONCLUSIONS Early RV-PA uncoupling is associated with reduced longitudinal function, whereas advanced RV-PA uncoupling is associated with reduced anteroposterior movement and LV preload, all in a risk-related fashion. CLINICALTRIALS GOV: NCT04663217.
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Affiliation(s)
- Zvonimir A Rako
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Athiththan Yogeswaran
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | | | | | - Selin Yildiz
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Bruno Brito da Rocha
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - István Vadász
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany; Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany; Department of Medicine, Imperial College London, London, UK
| | - Werner Seeger
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Henning Gall
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Nils C Kremer
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of 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, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Pascal Bauer
- Department of Cardiology & Angiology, University of Giessen, Giessen, Germany
| | - Ryan J Tedford
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | | | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, Hungary
| | - Khodr Tello
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany.
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Guo J, Wang J, Wang L, Li Y, Xu Y, Li W, Chen C, He J, Yin L, Pu S, Wen B, Han Y, Chen Y. Left ventricular underfilling in PAH: A potential indicator for adaptive-to-maladaptive transition. Pulm Circ 2023; 13:e12309. [PMID: 38045097 PMCID: PMC10689890 DOI: 10.1002/pul2.12309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 12/05/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) still remains a life-threatening disorder with poor prognosis. The right ventricle (RV) adapts to the increased afterload by a series of prognostically significant morphological and functional changes, the adaptive nature should also be understood in the context of ventricular interdependence. We hypothesized that left ventricle (LV) underfilling could serve as an important imaging marker for identifying maladaptive changes and predicting clinical outcomes in PAH patients. We prospectively enrolled patients with PAH who underwent both cardiac magnetic resonance and right heart catheterization between October 2013 and December 2020. Patients were categorized into four groups based on their LV and RV mass/volume ratio (M/V). LV M/V was stratified using the normal value (0.7 g/mL for males and 0.6 g/mL for females) to identify patients with LV underfilling (M/V ≥ normal value), while RV M/V was stratified based on the median value. The primary endpoint was all-cause mortality, and the composite endpoints included all-cause mortality and heart failure-related readmissions. A total of 190 PAH patients (53 male, mean age 37 years) were included in this study. Patients with LV underfilling exhibited higher NT-proBNP levels, increased RV mass, larger RV but smaller LV, lower right ventricular ejection fraction, and shorter 6-min walking distance. Patients with LV underfilling had a 2.7-fold higher risk of mortality than those without and LV M/V (hazard ratio [per 0.1 g/mL increase]: 1.271, 95% confidence interval: 1.082-1.494, p = 0.004) was also independent predictors of all-cause mortality. Moreover, patients with low LV M/V had a better prognosis regardless of the level of RV M/V. Thus, LV underfilling is an independent predictor of adverse clinical outcomes in patients with PAH, and it could be an important imaging marker for identifying maladaptive changes in these patients.
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Affiliation(s)
- Jiajun Guo
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Jiaqi Wang
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Lili Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Yangjie Li
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Yuanwei Xu
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Weihao Li
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Chen Chen
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Juan He
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Lidan Yin
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Shoufang Pu
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Bi Wen
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
| | - Yuchi Han
- Division of Cardiovascular Medicine, Wexner Medical Center, College of MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Yucheng Chen
- Department of Cardiology, West China HospitalSichuan UniversityChengduSichuanChina
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Kim SM, Randall EB, Jezek F, Beard DA, Chesler NC. Computational modeling of ventricular-ventricular interactions suggest a role in clinical conditions involving heart failure. Front Physiol 2023; 14:1231688. [PMID: 37745253 PMCID: PMC10512181 DOI: 10.3389/fphys.2023.1231688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/09/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction: The left (LV) and right (RV) ventricles are linked biologically, hemodynamically, and mechanically, a phenomenon known as ventricular interdependence. While LV function has long been known to impact RV function, the reverse is increasingly being realized to have clinical importance. Investigating ventricular interdependence clinically is challenging given the invasive measurements required, including biventricular catheterization, and confounding factors such as comorbidities, volume status, and other aspects of subject variability. Methods: Computational modeling allows investigation of mechanical and hemodynamic interactions in the absence of these confounding factors. Here, we use a threesegment biventricular heart model and simple circulatory system to investigate ventricular interdependence under conditions of systolic and diastolic dysfunction of the LV and RV in the presence of compensatory volume loading. We use the end-diastolic pressure-volume relationship, end-systolic pressure-volume relationship, Frank Starling curves, and cardiac power output as metrics. Results: The results demonstrate that LV systolic and diastolic dysfunction lead to RV compensation as indicated by increases in RV power. Additionally, RV systolic and diastolic dysfunction lead to impaired LV filling, interpretable as LV stiffening especially with volume loading to maintain systemic pressure. Discussion: These results suggest that a subset of patients with intact LV systolic function and diagnosed to have impaired LV diastolic function, categorized as heart failure with preserved ejection fraction (HFpEF), may in fact have primary RV failure. Application of this computational approach to clinical data sets, especially for HFpEF, may lead to improved diagnosis and treatment strategies and consequently improved outcomes.
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Affiliation(s)
- Salla M. Kim
- Department of Biomedical Engineering, Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center, University of California Irvine, Irvine, CA, United States
| | - E. Benjamin Randall
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, United States
| | - Filip Jezek
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, United States
- Department of Pathological Physiology, First Faculty of Medicine, Charles University, Prague, Czechia
| | - Daniel A. Beard
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, United States
| | - Naomi C. Chesler
- Department of Biomedical Engineering, Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center, University of California Irvine, Irvine, CA, United States
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Baratto C, Caravita S, Dewachter C, Faini A, Perego GB, Bondue A, Senni M, Muraru D, Badano LP, Parati G, Vachiéry JL. Right Heart Adaptation to Exercise in Pulmonary Hypertension: An Invasive Hemodynamic Study. J Card Fail 2023; 29:1261-1272. [PMID: 37150503 DOI: 10.1016/j.cardfail.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 04/12/2023] [Accepted: 04/12/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Right heart failure (RHF) is associated with a dismal prognosis in patients with pulmonary hypertension (PH). Exercise right heart catheterization may unmask right heart maladaptation as a sign of RHF. We sought to (1) define the normal limits of right atrial pressure (RAP) increase during exercise; (2) describe the right heart adaptation to exercise in PH owing to heart failure with preserved ejection fraction (PH-HFpEF) and in pulmonary arterial hypertension (PAH); and (3) identify the factors associated with right heart maladaptation during exercise. METHODS AND RESULTS We analyzed rest and exercise right heart catheterization from patients with PH-HFpEF and PAH. Right heart adaptation was described by absolute or cardiac output (CO)-normalized changes of RAP during exercise. Individuals with noncardiac dyspnea (NCD) served to define abnormal RAP responses (>97.5th percentile). Thirty patients with PH-HFpEF, 30 patients with PAH, and 21 patients with NCD were included. PH-HFpEF were older than PAH, with more cardiovascular comorbidities, and a higher prevalence of severe tricuspid regurgitation (P < .05). The upper limit of normal for peak RAP and RAP/CO slope in NCD were >12 mm Hg and ≥1.30 mm Hg/L/min, respectively. PH-HFpEF had higher peak RAP and RAP/CO slope than PAH (20 mm Hg [16-24 mm Hg] vs 12 mm Hg [9-19 mm Hg] and 3.47 mm Hg/L/min [2.02-6.19 mm Hg/L/min] vs 1.90 mm Hg/L/min [1.01-4.29 mm Hg/L/min], P < .05). A higher proportion of PH-HFpEF had RAP/CO slope and peak RAP above normal (P < .001). Estimated stressed blood volume at peak exercise was higher in PH-HFpEF than PAH (P < .05). In the whole PH cohort, the RAP/CO slope was associated with age, the rate of increase in estimated stressed blood volume during exercise, severe tricuspid regurgitation, and right atrial dilation. CONCLUSIONS Patients with PH-HFpEF display a steeper increase of RAP during exercise than those with PAH. Preload-mediated mechanisms may play a role in the development of exercise-induced RHF.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy.
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Andrea Faini
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano, Italy
| | | | - Antoine Bondue
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Michele Senni
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Jean-Luc Vachiéry
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy
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41
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Tello K, Naeije R, de Man F, Guazzi M. Pathophysiology of the right ventricle in health and disease: an update. Cardiovasc Res 2023; 119:1891-1904. [PMID: 37463510 DOI: 10.1093/cvr/cvad108] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/14/2023] [Accepted: 05/02/2023] [Indexed: 07/20/2023] Open
Abstract
The contribution of the right ventricle (RV) to cardiac output is negligible in normal resting conditions when pressures in the pulmonary circulation are low. However, the RV becomes relevant in healthy subjects during exercise and definitely so in patients with increased pulmonary artery pressures both at rest and during exercise. The adaptation of RV function to loading rests basically on an increased contractility. This is assessed by RV end-systolic elastance (Ees) to match afterload assessed by arterial elastance (Ea). The system has reserve as the Ees/Ea ratio or its imaging surrogate ejection fraction has to decrease by more than half, before the RV undergoes an increase in dimensions with eventual increase in filling pressures and systemic congestion. RV-arterial uncoupling is accompanied by an increase in diastolic elastance. Measurements of RV systolic function but also of diastolic function predict outcome in any cause pulmonary hypertension and heart failure with or without preserved left ventricular ejection fraction. Pathobiological changes in the overloaded RV include a combination of myocardial fibre hypertrophy, fibrosis and capillary rarefaction, a titin phosphorylation-related displacement of myofibril tension-length relationships to higher pressures, a metabolic shift from mitochondrial free fatty acid oxidation to cytoplasmic glycolysis, toxic lipid accumulation, and activation of apoptotic and inflammatory signalling pathways. Treatment of RV failure rests on the relief of excessive loading.
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Affiliation(s)
- Khodr Tello
- Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Klinikstrasse 36, 35392 Giessen, Germany
| | - Robert Naeije
- Pathophysiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium
| | - Frances de Man
- Pulmonary Medicine, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Marco Guazzi
- Cardiology Division, San Paolo University Hospital, University of Milano, Milano, Italy
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42
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Petit M, Vieillard-Baron A. Ventricular interdependence in critically ill patients: from physiology to bedside. Front Physiol 2023; 14:1232340. [PMID: 37614759 PMCID: PMC10442576 DOI: 10.3389/fphys.2023.1232340] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/27/2023] [Indexed: 08/25/2023] Open
Abstract
The review focuses on the mechanism of ventricular interdependence, a frequently encountered phenomena, especially in critically ill patients. It is explained by the anatomy of the heart, with two ventricles sharing a common wall, the septum, and nested in an acutely inextensible envelope, the pericardium. In pathological situation, it results in abnormal movements of the interventricular septum driven by respiration, leading to abnormal filling of one or the other ventricle. Ventricular interdependence has several clinical applications and explains some situations of hemodynamic impairment, especially in situations of cardiac tamponade, severe acute asthma, right ventricular (RV) overload, or more simply, in case of positive pressure ventilation with underlying acute pulmonary hypertension. Ventricular interdependence can be monitored with pulmonary arterial catheter or echocardiography. Knowledge of this phenomena has very concrete clinical applications in the management of filling or in the prevention or treatment of RV overload.
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Affiliation(s)
- Matthieu Petit
- Medical Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique–Hôpitaux de Paris, Boulogne-Billancourt, France
- Inserm, CESP, Paris-Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, Villejuif, France
| | - Antoine Vieillard-Baron
- Medical Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique–Hôpitaux de Paris, Boulogne-Billancourt, France
- Inserm, CESP, Paris-Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, Villejuif, France
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43
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Kenny JÉS, Gibbs SO, Eibl JK, Eibl AM, Yang Z, Johnston D, Munding CE, Elfarnawany M, Lau VC, Kemp BO, Nalla B, Atoui R. Simultaneous venous-arterial Doppler during preload augmentation: illustrating the Doppler Starling curve. Ultrasound J 2023; 15:32. [PMID: 37505318 PMCID: PMC10382420 DOI: 10.1186/s13089-023-00330-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/13/2023] [Indexed: 07/29/2023] Open
Abstract
Providing intravenous (IV) fluids to a patient with signs or symptoms of hypoperfusion is common. However, evaluating the IV fluid 'dose-response' curve of the heart is elusive. Two patients were studied in the emergency department with a wireless, wearable Doppler ultrasound system. Change in the common carotid arterial and internal jugular Doppler spectrograms were simultaneously obtained as surrogates of left ventricular stroke volume (SV) and central venous pressure (CVP), respectively. Both patients initially had low CVP jugular venous Doppler spectrograms. With preload augmentation, only one patient had arterial Doppler measures indicative of significant SV augmentation (i.e., 'fluid responsive'). The other patient manifested diminishing arterial response, suggesting depressed SV (i.e., 'fluid unresponsive') with evidence of ventricular asynchrony. In this short communication, we describe how a wireless, wearable Doppler ultrasound simultaneously tracks surrogates of cardiac preload and output within a 'Doppler Starling curve' framework; implications for IV fluid dosing are discussed.
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Affiliation(s)
- Jon-Émile S Kenny
- Health Sciences North Research Institute, Sudbury, ON, Canada.
- Flosonics Medical, 325 W. Front Street, Toronto, ON, Canada.
| | | | - Joseph K Eibl
- Health Sciences North Research Institute, Sudbury, ON, Canada
- Flosonics Medical, 325 W. Front Street, Toronto, ON, Canada
- NOSM University, Sudbury, ON, Canada
| | - Andrew M Eibl
- Health Sciences North Research Institute, Sudbury, ON, Canada
- Flosonics Medical, 325 W. Front Street, Toronto, ON, Canada
| | - Zhen Yang
- Flosonics Medical, 325 W. Front Street, Toronto, ON, Canada
| | | | | | | | - Vivian C Lau
- OSF Saint Francis Medical Center, Peoria, IL, USA
| | | | - Bhanu Nalla
- Health Sciences North Research Institute, Sudbury, ON, Canada
- NOSM University, Sudbury, ON, Canada
| | - Rony Atoui
- Health Sciences North Research Institute, Sudbury, ON, Canada
- NOSM University, Sudbury, ON, Canada
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44
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Molnár AÁ, Sánta A, Merkely B. Echocardiography Imaging of the Right Ventricle: Focus on Three-Dimensional Echocardiography. Diagnostics (Basel) 2023; 13:2470. [PMID: 37568832 PMCID: PMC10416971 DOI: 10.3390/diagnostics13152470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/28/2023] [Accepted: 07/21/2023] [Indexed: 08/13/2023] Open
Abstract
Right ventricular function strongly predicts cardiac death and adverse cardiac events in patients with cardiac diseases. However, the accurate right ventricular assessment by two-dimensional echocardiography is limited due to its complex anatomy, shape, and load dependence. Advances in cardiac imaging and three-dimensional echocardiography provided more reliable information on right ventricular volumes and function without geometrical assumptions. Furthermore, the pathophysiology of right ventricular dysfunction and tricuspid regurgitation is frequently connected. Three-dimensional echocardiography allows a more in-depth structural and functional evaluation of the tricuspid valve. Understanding the anatomy and pathophysiology of the right side of the heart may help in diagnosing and managing the disease by using reliable imaging tools. The present review describes the challenging echocardiographic assessment of the right ventricle and tricuspid valve apparatus in clinical practice with a focus on three-dimensional echocardiography.
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Affiliation(s)
- Andrea Ágnes Molnár
- Heart and Vascular Center, Semmelweis University, 1085 Budapest, Hungary; (A.S.); (B.M.)
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45
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Ltaief Z, Yerly P, Liaudet L. Pulmonary Hypertension in Left Heart Diseases: Pathophysiology, Hemodynamic Assessment and Therapeutic Management. Int J Mol Sci 2023; 24:9971. [PMID: 37373119 PMCID: PMC10298585 DOI: 10.3390/ijms24129971] [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: 05/08/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
Pulmonary hypertension (PH) associated with left heart diseases (PH-LHD), also termed group 2 PH, represents the most common form of PH. It develops through the passive backward transmission of elevated left heart pressures in the setting of heart failure, either with preserved (HFpEF) or reduced (HFrEF) ejection fraction, which increases the pulsatile afterload of the right ventricle (RV) by reducing pulmonary artery (PA) compliance. In a subset of patients, progressive remodeling of the pulmonary circulation resulted in a pre-capillary phenotype of PH, with elevated pulmonary vascular resistance (PVR) further increasing the RV afterload, eventually leading to RV-PA uncoupling and RV failure. The primary therapeutic objective in PH-LHD is to reduce left-sided pressures through the appropriate use of diuretics and guideline-directed medical therapies for heart failure. When pulmonary vascular remodeling is established, targeted therapies aiming to reduce PVR are theoretically appealing. So far, such targeted therapies have mostly failed to show significant positive effects in patients with PH-LHD, in contrast to their proven efficacy in other forms of pre-capillary PH. Whether such therapies may benefit some specific subgroups of patients (HFrEF, HFpEF) with specific hemodynamic phenotypes (post- or pre-capillary PH) and various degrees of RV dysfunction still needs to be addressed.
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Affiliation(s)
- Zied Ltaief
- Service of Adult Intensive Care Medicine, University Hospital, 1011 Lausanne, Switzerland;
| | - Patrick Yerly
- Service of Cardiology, University Hospital, 1011 Lausanne, Switzerland;
| | - Lucas Liaudet
- Service of Adult Intensive Care Medicine, University Hospital, 1011 Lausanne, Switzerland;
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46
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Hameed A, Condliffe R, Swift AJ, Alabed S, Kiely DG, Charalampopoulos A. Assessment of Right Ventricular Function-a State of the Art. Curr Heart Fail Rep 2023; 20:194-207. [PMID: 37271771 PMCID: PMC10256637 DOI: 10.1007/s11897-023-00600-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 06/06/2023]
Abstract
PURPOSE OF REVIEW The right ventricle (RV) has a complex geometry and physiology which is distinct from the left. RV dysfunction and failure can be the aftermath of volume- and/or pressure-loading conditions, as well as myocardial and pericardial diseases. RECENT FINDINGS Echocardiography, magnetic resonance imaging and right heart catheterisation can assess RV function by using several qualitative and quantitative parameters. In pulmonary hypertension (PH) in particular, RV function can be impaired and is related to survival. An accurate assessment of RV function is crucial for the early diagnosis and management of these patients. This review focuses on the different modalities and indices used for the evaluation of RV function with an emphasis on PH.
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Affiliation(s)
- Abdul Hameed
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Andrew J Swift
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- INSIGNEO, Institute for in silico Medicine, University of Sheffield, Sheffield, UK
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- INSIGNEO, Institute for in silico Medicine, University of Sheffield, Sheffield, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield, UK
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.
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47
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Naeije R, Tello K, D'Alto M. Tricuspid Regurgitation: Right Ventricular Volume Versus Pressure Load. Curr Heart Fail Rep 2023; 20:208-217. [PMID: 37099262 DOI: 10.1007/s11897-023-00599-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 04/27/2023]
Abstract
PURPOSE OF THE REVIEW Tricuspid regurgitation is associated with increased mortality in proportion to right ventricular adaptation to increased volume loading and pulmonary artery pressure. We here review recent progress in the understanding of right ventricular adaptation to pre- and after-loading conditions for improved recommendations of tricuspid valve repair. RECENT FINDINGS Trans-catheter tricuspid valve repair has made the correction of tricuspid regurgitation more easily available, triggering a need of tighter indications. Several studies have shown the feasibility and relevance to the indications of tricuspid valve repair of imaging of right ventricular ejection fraction measured by magnetic resonance imaging or 3D-echocardiography, and the 2D-echocardiography of the tricuspid annular plane systolic excursion to systolic pulmonary artery pressure ratio combined with invasively determined mean pulmonary artery pressure and pulmonary vascular resistance. Improved definitions of right ventricular failure and pulmonary hypertension may be considered in future recommendations on the treatment of tricuspid regurgitation.
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Affiliation(s)
- Robert Naeije
- Free University of Brussels, 808 Route de Lennik, B-1070, Brussels, Belgium.
| | - Khodr Tello
- Department of Internal Medicine, Institute for Lung Health, Cardiopulmonary Institute and Deutsches Zentrum Für LungenforschunUniversities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Michele D'Alto
- Department of Cardiology, Monaldi Hospital-"L. Vanvitelli" University, Naples, Italy
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48
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Bansal M, Mehta A, Machanahalli Balakrishna A, Kalyan Sundaram A, Kanwar A, Singh M, Vallabhajosyula S. RIGHT VENTRICULAR DYSFUNCTION IN SEPSIS: AN UPDATED NARRATIVE REVIEW. Shock 2023; 59:829-837. [PMID: 36943772 DOI: 10.1097/shk.0000000000002120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
ABSTRACT Sepsis is a multisystem disease process, which constitutes a significant public health challenge and is associated with high morbidity and mortality. Among other systems, sepsis is known to affect the cardiovascular system, which may manifest as myocardial injury, arrhythmias, refractory shock, and/or septic cardiomyopathy. Septic cardiomyopathy is defined as the reversible systolic and/or diastolic dysfunction of one or both ventricles. Left ventricle dysfunction has been extensively studied in the past, and its prognostic role in patients with sepsis is well documented. However, there is relatively scarce literature on right ventricle (RV) dysfunction and its role. Given the importance of timely detection of septic cardiomyopathy and its bearing on prognosis of patients, the role of RV dysfunction has come into renewed focus. Hence, through this review, we sought to describe the pathophysiology of RV dysfunction in sepsis and what have we learnt so far about its multifactorial nature. We also elucidate the roles of different biomarkers for its detection and prognosis, along with appropriate management of such patient population.
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Affiliation(s)
- Mridul Bansal
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Aryan Mehta
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | - Arvind Kalyan Sundaram
- Section of Cardiovascular Medicine, Department of Medicine, UMass Chan-Baystate Medical Center, Springfield, Massachusetts
| | | | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Yin X, Wang Y. Effect of pulmonary regurgitation on cardiac functions based on a human bi-ventricle model. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 238:107600. [PMID: 37285726 DOI: 10.1016/j.cmpb.2023.107600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/27/2023] [Accepted: 05/13/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND OBJECTIVE Assessing the severity of pulmonary regurgitation (PR) and identifying optimal clinically relevant indicators for its treatment is crucial, yet standards for quantifying PR remain unclear in clinical practice. Computational modelling of the heart is in the process of providing valuable insights and information for cardiovascular physiology research. However, the advancements of finite element computational models have not been widely applied to simulate cardiac outputs in patients with PR. Furthermore, a computational model that incorporates both the left ventricle (LV) and right ventricle (RV) can be valuable in assessing the relationship between left and right ventricular morphometry and septal motion in PR patients. To enhance our understanding of the effect of PR on cardiac functions and mechanical behaviour, we developed a human bi-ventricle model to simulate five cases with varying degrees of PR severity. METHODS This bi-ventricle model was built using a patient-specific geometry and a widely used myofibre architecture. The myocardial material properties were described by a hyperelastic passive constitutive law and a modified time-varying elastance active tension model. To simulate realistic cardiac functions and the dysfunction of the pulmonary valve in PR disease cases, open-loop lumped parameter models representing systemic and pulmonary circulatory systems were designed. RESULTS In the baseline case, pressures in the aorta and main pulmonary artery and ejection fractions of both the LV and RV were within normal physiological ranges reported in the literature. The end-diastolic volume (EDV) of the RV under varying degrees of PR was comparable to the reported cardiac magnetic resonance imaging data. Moreover, RV dilation and interventricular septum motion from the baseline to the PR cases were clearly observed through the long-axis and short-axis views of the bi-ventricle geometry. The RV EDV in the severe PR case increased by 50.3% compared to the baseline case, while the LV EDV decreased by 18.1%. The motion of the interventricular septum was consistent with the literature. Furthermore, ejection fractions of both the LV and RV decreased as PR became severe, with LV ejection fraction decreasing from 60.5% at baseline to 56.3% in the severe case and RV ejection fraction decreasing from 51.8% to 46.8%. Additionally, the average myofibre stress of the RV wall at end-diastole significantly increased due to PR, from 2.7±12.1 kPa at baseline to 10.9±26.5 kPa in the severe case. The average myofibre stress of the LV wall at end-diastole increased from 3.7±18.1 kPa to 4.3±20.3 kPa. CONCLUSIONS This study established a foundation for the computational modelling of PR. The simulated results showed that severe PR leads to reduced cardiac outputs in both the LV and RV, clearly observable septum motion, and a significant increase in the average myofibre stress in the RV wall. These findings demonstrate the potential of the model for further exploration of PR.
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Affiliation(s)
- Xueqing Yin
- School of Mathematics and Statistics, University of Glasgow, Glasgow, United Kingdom
| | - Yingjie Wang
- School of Mathematics and Statistics, University of Glasgow, Glasgow, United Kingdom.
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Shi R, Yang ZG, Guo YK, Qian WL, Gao Y, Li XM, Jiang L, Xu HY, Li Y. The right ventricular dysfunction and ventricular interdependence in patients with DM: assessment using cardiac MR feature tracking. Cardiovasc Diabetol 2023; 22:93. [PMID: 37085847 PMCID: PMC10122304 DOI: 10.1186/s12933-023-01806-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 03/16/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND To investigate the difference of right ventricular (RV) structural and functional alteration in patients with diabetes mellitus (DM) with preserved left ventricular ejection fraction (LVEF), and the ventricular interdependence in these patients, using cardiac MR (CMR) feature tracking. METHODS From December 2016 to February 2022, 148 clinically diagnosed patients with DM who underwent cardiac MR (CMR) in our hospital were consecutively recruited. Fifty-four healthy individuals were included as normal controls. Biventricular strains, including left/right ventricular global longitudinal strain (LV-/RVGLS), left/right ventricular global circumferential strain (LV-/RVGCS), left/right ventricular global radial strain (LV-/RVGRS) were evaluated, and compared between patients with DM and healthy controls. Multiple linear regression and mediation analyses were used to evaluate DM's direct and indirect effects on RV strains. RESULTS No differences were found in age (56.98 ± 10.98 vs. 57.37 ± 8.41, p = 0.985), sex (53.4% vs. 48.1%, p = 0.715), and body surface area (BSA) (1.70 ± 0.21 vs. 1.69 ± 0.17, p = 0.472) between DM and normal controls. Patients with DM had decreased RVGLS (- 21.86 ± 4.14 vs. - 24.49 ± 4.47, p = 0.001), RVGCS (- 13.16 ± 3.86 vs. - 14.92 ± 3.08, p = 0.011), and no decrease was found in RVGRS (22.62 ± 8.11 vs. 23.15 ± 9.05, p = 0.743) in patients with DM compared with normal controls. The difference in RVGLS between normal controls and patients with DM was totally mediated by LVGLS (indirect effecting: 0.655, bootstrapped 95%CI 0.138-0.265). The difference in RVGCS between normal controls and DM was partly mediated by the LVGLS (indirect effecting: 0.336, bootstrapped 95%CI 0.002-0.820) and LVGCS (indirect effecting: 0.368, bootstrapped 95%CI 0.028-0.855). CONCLUSIONS In the patients with DM and preserved LVEF, the difference in RVGLS between DM and normal controls was totally mediated by LVGLS. Although there were partly mediating effects of LVGLS and LVGCS, the decrease in RVGCS might be directly affected by the DM.
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Affiliation(s)
- Rui Shi
- Department of Radiology, West China Hospital, Sichuan University, No. 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Zhi-Gang Yang
- Department of Radiology, West China Hospital, Sichuan University, No. 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Ying-Kun Guo
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Wen-Lei Qian
- Department of Radiology, West China Hospital, Sichuan University, No. 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yue Gao
- Department of Radiology, West China Hospital, Sichuan University, No. 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Xue-Ming Li
- Department of Radiology, West China Hospital, Sichuan University, No. 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Li Jiang
- Department of Radiology, West China Hospital, Sichuan University, No. 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Hua-Yan Xu
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yuan Li
- Department of Radiology, West China Hospital, Sichuan University, No. 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
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