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Nielsen EA, Okumura K, Sun M, Hjortdal VE, Redington AN, Friedberg MK. Regional septal hinge-point injury contributes to adverse biventricular interactions in pulmonary hypertension. Physiol Rep 2018; 5:5/14/e13332. [PMID: 28733311 PMCID: PMC5532479 DOI: 10.14814/phy2.13332] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/28/2017] [Accepted: 06/03/2017] [Indexed: 11/24/2022] Open
Abstract
Death and morbidity in pulmonary arterial hypertension (PAH) are often due to right ventricular (RV) failure and associated left ventricular (LV) dysfunction. We investigated regional myocardial remodeling and function as the basis for adverse ventricular‐ventricular interactions in experimental chronic RV pressure overload. Two distinct animal models were studied: A rabbit model of increased RV pressure‐load through progressive pulmonary artery banding A rat model of monocrotaline (MCT)‐induced pulmonary arterial hypertension (PAH). Regional myocardial function was assessed by speckle‐tracking strain echocardiography and ventricular pressures measured by catheterization before termination. Regional RV and LV myocardium was analyzed for collagen content, apoptosis and pro‐fibrotic signaling gene and protein expression. Although the RV developed more fibrosis than the LV; in both models the LV was substantially affected. In both ventricles, particularly the LV, fibrosis developed predominantly at the septal hinge‐point regions in association with decreased regional and global circumferential strain, reduced global RV and LV function and up‐regulation of regional transforming growth factor‐β1 (TGFβ1) and apoptosis signaling. A group of PAH rats who received the TGFβ blocker SB431542 showed improved RV function and reduced regional hinge‐point myocardial fibrosis. RV pressure‐loading and PAH lead to biventricular TGFβ1 signaling, fibrosis and apoptosis, predominantly at the septal hinge‐point regions, in association with regional myocardial dysfunction. This suggests that altered geometry and wall stress lead to adverse RV‐LV interactions through the septal hinge‐points to induce LV fibrosis and dysfunction.
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Affiliation(s)
- Eva Amalie Nielsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Kenichi Okumura
- The Labatt Family Heart Center and Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mei Sun
- The Labatt Family Heart Center and Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vibeke E Hjortdal
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Andrew N Redington
- The Labatt Family Heart Center and Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mark K Friedberg
- The Labatt Family Heart Center and Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
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Badagliacca R, Raina A, Ghio S, D’Alto M, Confalonieri M, Correale M, Corda M, Paciocco G, Lombardi C, Mulè M, Poscia R, Scelsi L, Argiento P, Sciomer S, Benza RL, Vizza CD. Influence of various therapeutic strategies on right ventricular morphology, function and hemodynamics in pulmonary arterial hypertension. J Heart Lung Transplant 2018; 37:365-375. [DOI: 10.1016/j.healun.2017.08.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 08/03/2017] [Accepted: 08/24/2017] [Indexed: 01/22/2023] Open
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Foschi M, Di Mauro M, Tancredi F, Capparuccia C, Petroni R, Leonzio L, Romano S, Gallina S, Penco M, Cibelli M, Calafiore A. The Dark Side of the Moon: The Right Ventricle. J Cardiovasc Dev Dis 2017; 4:jcdd4040018. [PMID: 29367547 PMCID: PMC5753119 DOI: 10.3390/jcdd4040018] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/16/2017] [Accepted: 10/19/2017] [Indexed: 01/28/2023] Open
Abstract
The aim of this review article is to summarize current knowledge of the pathophysiology underlying right ventricular failure (RVF), focusing, in particular, on right ventricular assessment and prognosis. The right ventricle (RV) can tolerate volume overload well, but is not able to sustain pressure overload. Right ventricular hypertrophy (RVH), as a response to increased afterload, can be adaptive or maladaptive. The easiest and most common way to assess the RV is by two-dimensional (2D) trans-thoracic echocardiography measuring surrogate indexes, such as tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tissue Doppler velocity of the lateral aspect of the tricuspid valvular plane. However, both volumes and function are better estimated by 3D echocardiography and cardiac magnetic resonance (CMR). The prognostic role of the RV in heart failure (HF), pulmonary hypertension (PH), acute myocardial infarction (AMI), and cardiac surgery has been overlooked for many years. However, several recent studies have placed much greater importance on the RV in prognostic assessments. In conclusion, RV dimensions and function should be routinely assessed in cardiovascular disease, as RVF has a significant impact on disease prognosis. In the presence of RVF, different therapeutic approaches, either pharmacological or surgical, may be beneficial.
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Affiliation(s)
| | - Michele Di Mauro
- Chair of Cardiology, University of L'Aquila, 67100 L'Aquila, Italy.
| | - Fabrizio Tancredi
- Department of Heart Disease, SS Annunziata Hospital, 66100 Chieti, Italy.
| | - Carlo Capparuccia
- Department of Heart Disease, SS Annunziata Hospital, 66100 Chieti, Italy.
| | - Renata Petroni
- Chair of Cardiology, University of L'Aquila, 67100 L'Aquila, Italy.
| | - Luigi Leonzio
- Department of Heart Disease, SS Annunziata Hospital, 66100 Chieti, Italy.
| | - Silvio Romano
- Chair of Cardiology, University of L'Aquila, 67100 L'Aquila, Italy.
| | - Sabina Gallina
- Cardiology, University "Gabriele D'Annunzio"of Chieti-Pescara, 66100 Chieti, Italy.
| | - Maria Penco
- Chair of Cardiology, University of L'Aquila, 67100 L'Aquila, Italy.
| | - Mario Cibelli
- Department of Cardiothoracic Anaesthesia, University Hospitals Birmingham, Birmingham B15 2TH, UK.
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New predictors of mortality in adults with congenital heart disease and pulmonary hypertension: Midterm outcome of a prospective study. Int J Cardiol 2015; 181:270-6. [DOI: 10.1016/j.ijcard.2014.11.222] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 11/12/2014] [Accepted: 11/26/2014] [Indexed: 11/22/2022]
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Affiliation(s)
- Mark K. Friedberg
- From the Labatt Family Heart Center, Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Andrew N. Redington
- From the Labatt Family Heart Center, Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
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Schuuring MJ, van Riel AC, Vis JC, Duffels MG, van Straalen JP, Boekholdt SM, Tijssen JG, Mulder BJ, Bouma BJ. High-sensitivity Troponin T Is Associated with Poor Outcome in Adults with Pulmonary Arterial Hypertension due to Congenital Heart Disease. CONGENIT HEART DIS 2012; 8:520-6. [DOI: 10.1111/chd.12022] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2012] [Indexed: 11/27/2022]
Affiliation(s)
- Mark J. Schuuring
- Department of Cardiology; Academic Medical Center; Amsterdam The Netherlands
- Interuniversity Cardiology Institute of the Netherlands; Utrecht The Netherlands
| | - Annelieke C.M.J. van Riel
- Department of Cardiology; Academic Medical Center; Amsterdam The Netherlands
- Interuniversity Cardiology Institute of the Netherlands; Utrecht The Netherlands
| | - Jeroen C. Vis
- Department of Cardiology; Academic Medical Center; Amsterdam The Netherlands
| | - Marielle G. Duffels
- Department of Cardiology; Academic Medical Center; Amsterdam The Netherlands
| | - Jan P. van Straalen
- Department of Clinical Chemistry; Academic Medical Center; Amsterdam The Netherlands
| | | | - Jan G.P. Tijssen
- Department of Cardiology; Academic Medical Center; Amsterdam The Netherlands
| | - Barbara J.M. Mulder
- Department of Cardiology; Academic Medical Center; Amsterdam The Netherlands
| | - Berto J. Bouma
- Department of Cardiology; Academic Medical Center; Amsterdam The Netherlands
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Schuuring MJ, Vis JC, Bouma BJ, van Dijk AP, van Melle JP, Pieper PG, Vliegen HW, Sieswerda GT, Mulder BJ. Rationale and design of a trial on the role of bosentan in Fontan patients: Improvement of exercise capacity? Contemp Clin Trials 2011; 32:586-91. [DOI: 10.1016/j.cct.2011.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Revised: 03/16/2011] [Accepted: 04/04/2011] [Indexed: 10/18/2022]
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Schuuring MJ, Vis JC, Duffels MG, Bouma BJ, Mulder BJ. Adult patients with pulmonary arterial hypertension due to congenital heart disease: a review on advanced medical treatment with bosentan. Ther Clin Risk Manag 2010; 6:359-66. [PMID: 20856682 PMCID: PMC2940744 DOI: 10.2147/tcrm.s8397] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Indexed: 01/21/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease with poor survival outcome. PAH is classified by the 2009 updated clinical classification of pulmonary hypertension and a major subgroup is PAH due to congenital heart disease (CHD) with systemic-to-pulmonary shunt. CHD-PAH is a result of systemic-to-pulmonary shunting and chronic increased flow that ultimately results in adaptations of pulmonary vasculature and endothelial dysfunction. The advanced stage is called Eisenmenger syndrome which forms a small percentage (1%) of all CHD patients. Therapies targeted on PAH symptoms are called primary therapy for PAH, but most CHD-PAH patients progress to advanced therapy which is directed at the PAH itself. In CHD-PAH, advanced therapies are extensively investigated for all three major pathways: endothelin-1 receptor antagonists such as bosentan, prostanoids such as epoprostenol and phosphodiesterase 5 inhibitors such as sildenafil. Endpoints in most trials were catheterization hemodynamics, World Health Organization functional class, six-minute walking distance and patient-focused outcomes, based on quality of life questionnaires and Borg dyspnea index. The BREATHE-5 and EARLY study were two important randomized controlled trials showing efficacy of bosentan at short follow-up. Moreover in patients with Eisenmenger syndrome, one recent survival retrospective study with majority of patients on bosentan showed strong survival benefit over conservative therapy. A diversity of prospective cohort and retrospective studies were performed but all with limited data, due to small numbers and heterogeneity of underlying CHD diagnoses. Further larger studies are needed to determine optimal treatment for adults with CHD-PAH. This review focuses on bosentan in CHD-PAH. In particular, we discuss outcome of various clinical trials and compare efficacy and safety of bosentan to other advanced therapies.
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Affiliation(s)
- Mark J Schuuring
- Department of Cardiology, Academic Medical Centre, Amsterdam, The Netherlands
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Do we have two hearts? New insights in right ventricular function supported by myocardial imaging echocardiography. Heart Fail Rev 2010; 15:39-61. [PMID: 19866357 DOI: 10.1007/s10741-009-9154-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
RV performance is difficult to evaluate, given its geometry, interrelationship with the left ventricle, and sensitivity to alterations in pulmonary pressure. This article focuses on some of the challenges related to the assessment of RV function in the setting of the RV's unique anatomic, physiologic, conventional and newer echocardiographic aspects, and therapeutic implications. The majority of proposed methods of echocardiographic assessment of RV function are based on volumetric approximations of the RV. Such approaches have inherent limitations, first as volume-related measures such as EF are load dependent, second because of the complex geometry of the RV. The issue of RV geometry is usually overcome using geometry-independent parameters such as tricuspid annular excursion and the Tei index. The recent introduction of real-time three-dimensional echocardiography and myocardial imaging echocardiography (tissue Doppler imaging, 1D-strain and 2D-strain echocardiography) implied a great progress in echocardiography. Tissue Doppler imaging allows the quantitative assessment of RV systolic and diastolic function by means of measurement of myocardial velocities. Strain measurements have been shown to correlate well with sonomicrometry segment length measurements both in the inflow and outflow tract of the RV and under different loading conditions. Other findings have been reported in chronic and acute clinical settings. Standard and novel echocardiographic methods of assessment of RV size and performance can help clinicians in the treatment of acute and chronic RV failure and contribute to a better understanding of the peculiar chamber-related functional mechanisms in the context of ventricular interdependent independency.
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Efficacy, safety and tolerability of bosentan in Chinese patients with pulmonary arterial hypertension. J Heart Lung Transplant 2010; 29:150-6. [DOI: 10.1016/j.healun.2009.09.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Revised: 09/16/2009] [Accepted: 09/20/2009] [Indexed: 01/03/2023] Open
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