1
|
Chin KM, Gaine SP, Gerges C, Jing ZC, Mathai SC, Tamura Y, McLaughlin VV, Sitbon O. Treatment algorithm for pulmonary arterial hypertension. Eur Respir J 2024:2401325. [PMID: 39209476 DOI: 10.1183/13993003.01325-2024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 07/09/2024] [Indexed: 09/04/2024]
Abstract
Pulmonary arterial hypertension leads to significant impairment in haemodynamics, right heart function, exercise capacity, quality of life and survival. Current therapies have mechanisms of action involving signalling via one of four pathways: endothelin-1, nitric oxide, prostacyclin and bone morphogenetic protein/activin signalling. Efficacy has generally been greater with therapeutic combinations and with parenteral therapy compared with monotherapy or nonparenteral therapies, and maximal medical therapy is now four-drug therapy. Lung transplantation remains an option for selected patients with an inadequate response to therapies.
Collapse
Affiliation(s)
- Kelly M Chin
- Division of Pulmonary and Critical Care Medicine, UT Southwestern, Dallas, TX, USA
| | - Sean P Gaine
- Department of Respiratory Medicine, National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Christian Gerges
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Zhi-Cheng Jing
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Yuichi Tamura
- Pulmonary Hypertension Center, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Vallerie V McLaughlin
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
- Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Olivier Sitbon
- Department of Respiratory Medicine, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France
- Université Paris-Saclay, Le Kremlin-Bicêtre, France
| |
Collapse
|
2
|
Chooklin S, Chuklin S, Posivnych M, Krystopchuk S. Portopulmonary hypertension: peculiarities of diagnosis and treatment. EMERGENCY MEDICINE 2024; 20:146-158. [DOI: 10.22141/2224-0586.20.3.2024.1686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Portopulmonary hypertension is defined as the development of pulmonary hypertension secondary to portal one. Its exact prevalence is difficult to determine due to the lack of routine screening in patients with portal hypertension. Hemodynamic changes associated with portal hypertension, including the hyperdynamic state, portosystemic shunts, and splanchnic vasodilation, cause significant disturbances in the pulmonary vasculature and play a key role in the pathogenesis of the disease. Without treatment, portopulmonary hypertension leads to progressive right ventricular failure with a poor prognosis. Although Doppler echocardiography is the best initial screening tool for symptomatic patients and candidates for liver transplant, right heart catheterization remains the gold standard for disease diagnosis. Treatment of patients with portopulmonary hypertension is aimed at improving cardiac function, reducing pulmonary vascular resistance, and optimizing functional capacity. Pulmonary hypertension-specific therapy, which includes prostacyclin and its receptor agonists, endothelin receptor antagonists, phosphodiesterase inhibitors, and guanylate cyclase stimulators, plays a key role in the treatment of patients with portopulmonary hypertension. Small uncontrolled and recent single randomized controlled trials have reported promising results of vasodilator therapy in terms of clinical and hemodynamic improvement in patients, allowing certain patients to undergo liver transplantation. This review discusses the epidemiology, approach to diagnosis and treatment of patients with portopulmonary hypertension. We used MEDLINE database on the PubMed platform and the Cochrane library to search for literature sources using the keywords: portopulmonary hypertension, portal hypertension, pulmonary hypertension, liver cirrhosis, pulmonary complications.
Collapse
|
3
|
Kim NH, Chin KM, McLaughlin VV, DuBrock H, Restrepo-Jaramillo R, Safdar Z, MacDonald G, Martin N, Rosenberg D, Solonets M, Channick R. Safety of Macitentan for the Treatment of Portopulmonary Hypertension: Real-World Evidence from the Combined OPUS/OrPHeUS Studies. Pulm Ther 2024; 10:85-107. [PMID: 38184507 PMCID: PMC10881949 DOI: 10.1007/s41030-023-00251-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/14/2023] [Indexed: 01/08/2024] Open
Abstract
INTRODUCTION Portopulmonary hypertension (PoPH) carries a worse prognosis than other forms of pulmonary arterial hypertension (PAH). Data regarding use of PAH-specific therapies in patients with PoPH are sparse as they are usually excluded from clinical trials. This analysis describes patient characteristics, treatment patterns, outcomes, and safety profiles in patients with PoPH newly initiating macitentan in the USA using the OPUS/OrPHeUS combined dataset. METHODS OPUS was a prospective, US, multicenter, observational drug registry (April 2014-June 2020); OrPHeUS was a retrospective, US, multicenter chart review (October 2013-March 2017). Additional information regarding patients' liver disease was retrospectively collected for patients with PoPH in OPUS. RESULTS The OPUS/OrPHeUS dataset included 206 patients with PoPH (median age 58 years; 52.4% female), with baseline cirrhosis and liver test abnormalities reported in 72.8% and 31.6% of patients respectively. Macitentan was initiated as combination therapy in 74.8% of patients and median (Q1, Q3) exposure to macitentan was 11.9 (3.1, 26.0) months. One-year Kaplan-Meier estimates (95% confidence limit, CL) of patients free from all-cause hospitalization and survival were 48.6% (40.7, 56.0) and 82.2% (75.1, 87.4). Of the 96 patients with PoPH in OPUS, 29.2% were classified as in need of liver transplant due to underlying liver disease during the study; transplant waitlist registration was precluded because of PAH severity for 32.1% and 17.9% were transplanted. Hepatic adverse events (HAE) were experienced by 49.0% of patients; the most common being increased bilirubin (16.0%), ascites (7.3%), and hepatic encephalopathy (5.8%); 1.5% and 21.8% of patients discontinued macitentan as a result of HAE and non-hepatic adverse events. CONCLUSION There were no unexpected safety findings in patients with PoPH treated with macitentan. These data add to the evidence supporting the safety and tolerability of macitentan in patients with PoPH. A graphical abstract is available with this article. TRIAL REGISTRATION OPsumit® Users Registry (OPUS): NCT02126943; OPsumit® Historical Users cohort (OrPHeUS): NCT03197688; www. CLINICALTRIALS gov .
Collapse
Affiliation(s)
- Nick H Kim
- UC San Diego Health, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, 9300 Campus Point Dr, La Jolla, CA, 92037-7381, USA.
| | | | | | | | | | - Zeenat Safdar
- Houston Methodist, Weill Cornell Medical College, Houston, TX, USA
| | - Gwen MacDonald
- Global Medical Affairs, Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Allschwil, Switzerland
| | - Nicolas Martin
- Statistical Decision Science, Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Allschwil, Switzerland
| | - Daniel Rosenberg
- Global Epidemiology, Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Allschwil, Switzerland
| | - Maria Solonets
- Global Medical Safety, Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson and Johnson, Allschwil, Switzerland
| | - Richard Channick
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
4
|
Harder EM, Divo MJ, Washko GR, Leopold JA, Rahaghi FN, Waxman AB. Implications of Mean Pulmonary Arterial Wedge Pressure Trajectories in Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2024; 209:316-324. [PMID: 37939220 PMCID: PMC10840771 DOI: 10.1164/rccm.202306-1072oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/18/2023] [Indexed: 11/10/2023] Open
Abstract
Rationale: The mean pulmonary arterial wedge pressure (mPAWP) is the critical hemodynamic factor differentiating group 1 pulmonary arterial hypertension (PAH) from group 2 pulmonary hypertension associated with left heart disease. Despite the discrepancy between the mPAWP upper physiologic normal and current PAH definitions, the implications of the initial mPAWP for PAH clinical trajectory are poorly understood. Objectives: To model longitudinal mPAWP trajectories in PAH over 10 years and examine the clinical and hemodynamic factors associated with trajectory membership. Methods: Adult patients with PAH with two or more right heart catheterizations were identified from a multiinstitution healthcare system in eastern Massachusetts. mPAWP trajectories were constructed via group-based trajectory modeling. Feature selection was performed in least absolute shrinkage and selection operator regression. Logistic regression was used to assess associations between trajectory membership, baseline characteristics, and transplant-free survival. Measurements and Main Results: Among 301 patients with PAH, there were two distinct mPAWP trajectories, termed "mPAWP-high" (n = 71; 23.6%) and "mPAWP-low" (n = 230; 76.4%), based on the ultimate mPAWP value. Initial mPAWP clustered around median 12 mm Hg (interquartile range [IQR], 8-14 mm Hg) in the mPAWP-high and 9 mm Hg (IQR, 6-11 mm Hg) in the mPAWP-low trajectories (P < 0.001). After feature selection, initial mPAWP ⩾12 mm Hg predicted an mPAWP-high trajectory (odds ratio, 3.2; 95% confidence interval, 1.4-6.1; P = 0.0006). An mPAWP-high trajectory was associated with shorter transplant-free survival (vs. mPAWP-low, median, 7.8 vs. 11.3 yr; log-rank P = 0.017; age-adjusted P = 0.217). Conclusions: Over 10 years, the mPAWP followed two distinct trajectories, with 25% evolving into group 2 pulmonary hypertension physiology. Using routine baseline data, longitudinal mPAWP trajectory could be predicted accurately, with initial mPAWP ⩾12 mm Hg as one of the strongest predictors.
Collapse
Affiliation(s)
| | | | | | - Jane A. Leopold
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | | |
Collapse
|
5
|
Mahmoud AK, Abbas MT, Kamel MA, Farina JM, Pereyra M, Scalia IG, Barry T, Chao CJ, Marcotte F, Ayoub C, Scott RL, Majdalany DS, Arsanjani R. Current Management and Future Directions for Pulmonary Arterial Hypertension Associated with Congenital Heart Disease. J Pers Med 2023; 14:5. [PMID: 38276220 PMCID: PMC10817644 DOI: 10.3390/jpm14010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/12/2023] [Accepted: 12/16/2023] [Indexed: 01/27/2024] Open
Abstract
Current management of patients with congenital heart disease has increased their survival into adulthood. This is accompanied by potential cardiac complications, including pulmonary hypertension associated with congenital heart disease (PAH-CHD). PAH-CHD constitutes a challenging subgroup of pulmonary hypertension and requires expert management to improve quality of life and prognosis. Novel agents have shown a significant improvement in morbidity and mortality in patients with pulmonary arterial hypertension. However, the long-term effects of these medications on PAH-CHD patients remain somewhat uncertain, necessitating treatment plans largely founded on the clinical experience of the healthcare providers. The aim of this review is to summarize the current evidence and future perspectives regarding treatment strategies for PAH-CHD to help better guide management of this complex disease.
Collapse
Affiliation(s)
- Ahmed K. Mahmoud
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Mohammed Tiseer Abbas
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Moaz A. Kamel
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Juan M. Farina
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Isabel G. Scalia
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Timothy Barry
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Chieh-Ju Chao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Francois Marcotte
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Robert L. Scott
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - David S. Majdalany
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.)
| |
Collapse
|
6
|
Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 543] [Impact Index Per Article: 543.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | | |
Collapse
|
7
|
Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 1227] [Impact Index Per Article: 613.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
|
8
|
Akhtar S. Preoperative evaluation of geriatric patients undergoing liver transplantation. Curr Opin Anaesthesiol 2022; 35:96-104. [PMID: 34878418 DOI: 10.1097/aco.0000000000001084] [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: 11/26/2022]
Abstract
PURPOSE OF REVIEW As the population of the world is aging the number of geriatric patients undergoing liver transplantation (LT) is also increasing. They pose a unique challenge for the caregivers, as they have age-related physiological changes, multiple comorbidities and cirrhosis-related pathologies. RECENT FINDINGS Twenty-two percent of patients who undergo LT are older than 65 years. Many patients suffer from nonalcoholic steatohepatitis (NASH), hepatocellular carcinoma and hepatitis-C virus. Incidence of NASH tends to increase with age, obesity, diabetes and metabolic syndrome. Elderly patients require comprehensive cognitive, cardiac and pulmonary evaluation prior to LT. Cirrhotic cardiomyopathy, hepatopulmonary syndrome, portopulmonary hypertension and frailty are of specific concern. SUMMARY Proportion of elderly patients who are undergoing LT continues to increase. These patients require comprehensive cardiopulmonary and frailty evaluation. Consensus-based practice advisories need to be developed to standardize preoperative evaluation of geriatric patients awaiting LT.
Collapse
Affiliation(s)
- Shamsuddin Akhtar
- Department of Anesthesiology and Pharmacology, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
9
|
Del Valle K, DuBrock HM. Hepatopulmonary Syndrome and Portopulmonary Hypertension: Pulmonary Vascular Complications of Liver Disease. Compr Physiol 2021; 11:3281-3302. [PMID: 34636408 DOI: 10.1002/cphy.c210009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pulmonary vascular disease is a frequent complication of chronic liver disease and portal hypertension, affecting up to 30% of patients. There are two distinct pulmonary vascular complications of liver disease: hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH). HPS affects 25% of patients with chronic liver disease and is characterized by intrapulmonary vasodilatation and abnormal arterial oxygenation. HPS negatively impacts quality of life and is associated with a 2-fold increased risk of death compared to controls with liver disease without HPS. Angiogenesis, endothelin-1 mediated endothelial dysfunction, monocyte influx, and alveolar type 2 cell dysfunction seem to play important roles in disease pathogenesis but there are currently no effective medical therapies. Fortunately, HPS resolves following liver transplant (LT) with improvements in hypoxemia. POPH is a subtype of pulmonary arterial hypertension (PAH) characterized by an elevated mean pulmonary arterial pressure and pulmonary vascular resistance in the setting of normal left-sided filling pressures. POPH affects 5% to 6% of patients with chronic liver disease. Although the pathogenesis has not been fully elucidated, endothelial dysfunction, inflammation, and estrogen signaling have been identified as key pathways involved in disease pathogenesis. POPH is typically treated with PAH targeted therapy and may also improve with liver transplantation in selected patients. This article highlights what is currently known regarding the diagnosis, management, pathobiology, and outcomes of HPS and POPH. Ongoing research is needed to improve understanding of the pathophysiology and outcomes of these distinct and often misunderstood pulmonary vascular complications of liver disease. © 2021 American Physiological Society. Compr Physiol 11:1-22, 2021.
Collapse
|
10
|
Le Fevre ER, McGrath KH, Fitzgerald DA. Pulmonary Manifestations of Gastrointestinal, Pancreatic, and Liver Diseases in Children. Pediatr Clin North Am 2021; 68:41-60. [PMID: 33228942 DOI: 10.1016/j.pcl.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pulmonary manifestations of gastrointestinal (GI) diseases are often subtle, and underlying disease may precede overt symptoms. A high index of suspicion and a low threshold for consultation with a pediatric pulmonologist is warranted in common GI conditions. This article outlines the pulmonary manifestations of different GI, pancreatic, and liver diseases in children, including gastroesophageal reflux disease, inflammatory bowel disease, pancreatitis, alpha1-antitrypsin deficiency, nonalcoholic fatty liver disease, and complications of chronic liver disease (hepatopulmonary syndrome and portopulmonary hypertension).
Collapse
Affiliation(s)
- Emily R Le Fevre
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, New South Wales 2145, Australia
| | - Kathleen H McGrath
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, New South Wales 2145, Australia; Faculty Health Sciences, University of Sydney, Sydney, New South Wales, Australia.
| |
Collapse
|
11
|
Öz A, Çınar T, Taş E, Çağan Efe S, Ayça B, Karabağ T. Assessment of pulmonary arterial stiffness in patients with cirrhosis: A prospective cohort study. Echocardiography 2020; 38:57-63. [PMID: 33226143 DOI: 10.1111/echo.14935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/21/2020] [Accepted: 11/04/2020] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION In the current literature, several studies show that PAS (pulmonary artery stiffness) is associated with RV (right ventricular) dysfunction, PAH (pulmonary arterial hypertension), and disease severity in subjects with structural cardiac disease, HIV (human immunodeficiency virus), and chronic lung disease. Hence, our main aim was to use PAS to show the early changes in the pulmonary vascular region in subjects with cirrhosis. MATERIAL AND METHODS In this prospective cross-sectional study, 39 subjects who were being followed up with cirrhosis and 41 age- and sex-matched healthy subjects were included in this study. For each case, the PAS value was obtained by dividing mean peak velocity of the pulmonary flow by the PfAT (pulmonary flow acceleration time). RESULTS The measured PAS was 23.62 ± 5.87 (Hz/msn) in cirrhotic participants and 19.09 ± 4.16 (Hz/msn) in healthy cases (P < .001). We found a positive statistical significance between PAS and RVSP (right ventricle systolic pressure)/sPAP (systolic pulmonary arterial pressure) (r = .395; P = .013). PAS was an independent predictor that was associated with cirrhosis disease according to multivariate LR (logistic regression) analysis (OR: 1.209; 95% CI: 1.059-1.381; P = .005). CONCLUSION Based on the study results, we consider that PAS may help in the early detection of findings in the pulmonary vascular area, even if the RV function findings or sPAP is within the normal range.
Collapse
Affiliation(s)
- Ahmet Öz
- Department of Cardiology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Tufan Çınar
- Department of Cardiology, Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
| | - Ebru Taş
- Department of Gastroenterology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Süleyman Çağan Efe
- Department of Cardiology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Burak Ayça
- Department of Cardiology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Turgut Karabağ
- Department of Cardiology, Istanbul Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
12
|
Sahay S, Tsang Y, Flynn M, Agron P, Dufour R. Burden of pulmonary hypertension in patients with portal hypertension in the United States: a retrospective database study. Pulm Circ 2020; 10:2045894020962917. [PMID: 33282188 PMCID: PMC7686640 DOI: 10.1177/2045894020962917] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/10/2020] [Indexed: 01/29/2023] Open
Abstract
Patients with portal hypertension may develop pulmonary hypertension. The
economic implications of these comorbidities have not been systematically
assessed. We compared healthcare resource utilization and costs in the United
States between patients with co-existing portal hypertension and pulmonary
hypertension (pulmonary hypertension cohort) and a matched cohort of portal
hypertension patients without pulmonary hypertension (control cohort). In this
retrospective analysis, adult pulmonary hypertension and control patients were
identified from the Optum® Clinformatics® Data Mart database between 1 July 2014
and 30 June 2018. All patients had ≥2 claims with diagnosis codes for portal
hypertension; pulmonary hypertension patients had ≥2 claims with diagnosis codes
for pulmonary hypertension; controls could not have pulmonary hypertension
diagnoses or any claims for pulmonary arterial hypertension-specific
medications. Controls were matched to pulmonary hypertension patients by age,
sex, Charlson comorbidity index score, and liver diseases. We assessed 12-month
healthcare resource utilization and costs. Each cohort included 146 patients.
During follow-up, pulmonary hypertension cohort patients were more likely than
controls to experience a hospitalization (51% vs. 32%,
P = 0.0014) and an emergency room visit (55% vs. 41%,
P = 0.026). The average annual total cost was higher in
pulmonary hypertension patients than for matched controls ($119,912 vs. $81,839,
P < 0.0001). After covariate adjustment, costs for
pulmonary hypertension cohort patients were 1.47 times higher than those for
controls (P = 0.0197). These findings suggest that patients
with portal hypertension and co-existing pulmonary hypertension are at a greater
risk for hospitalization and incur higher mean annual total costs than portal
hypertension patients without pulmonary hypertension.
Collapse
Affiliation(s)
- Sandeep Sahay
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, Institute of Academic Medicine, Houston Methodist Hospital, Houston, USA
| | - Yuen Tsang
- Actelion Pharmaceuticals US, Inc., a Janssen Pharmaceutical Company of Johnson & Johnson, South San Francisco, USA
| | - Megan Flynn
- Actelion Pharmaceuticals US, Inc., a Janssen Pharmaceutical Company of Johnson & Johnson, South San Francisco, USA
| | - Peter Agron
- Actelion Pharmaceuticals US, Inc., a Janssen Pharmaceutical Company of Johnson & Johnson, South San Francisco, USA
| | - Robert Dufour
- Actelion Pharmaceuticals US, Inc., a Janssen Pharmaceutical Company of Johnson & Johnson, South San Francisco, USA
| |
Collapse
|
13
|
Krowka M, Cottreel E, Hoeper MM, Kim NH, Martin N, Sitbon O, Bosch J. Macitentan Improves Risk Categorization for Liver Transplant Mortality in Patients With Portopulmonary Hypertension: A PORTICO Study Post Hoc Analysis. Liver Transpl 2020; 26:935-940. [PMID: 32150762 PMCID: PMC7383602 DOI: 10.1002/lt.25747] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/20/2020] [Accepted: 03/04/2020] [Indexed: 12/12/2022]
Affiliation(s)
| | | | - Marius M. Hoeper
- Hannover Medical School and German Center of Lung ResearchHannoverGermany
| | - Nick H. Kim
- University of California, San DiegoLa JollaCA
| | | | - Olivier Sitbon
- University Paris‐SaclayLe Kremlin‐BicêtreFrance,Department of Respiratory MedicineBicêtre Hospital, AP‐HPLe Kremlin‐BicêtreFrance,INSERMUMR_S999Le Plessis‐RobinsonFrance
| | - Jaume Bosch
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y DigestivasUniversity of BarcelonaBarcelonaSpain,Department of Biomedical Research, Department of HepatologyUniversity Clinic for Visceral Surgery and MedicineInselspitalBern UniversityBernSwitzerland
| |
Collapse
|
14
|
Vachiéry JL, Galiè N. Beyond the World Symposium on Pulmonary Hypertension: practical management of pulmonary arterial hypertension and evolving concepts. Eur Heart J Suppl 2019; 21:K1-K3. [PMID: 31857794 PMCID: PMC6915054 DOI: 10.1093/eurheartj/suz209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Jean-Luc Vachiéry
- Department of Cardiology, Pulmonary Hypertension and Heart Failure Clinic, Cliniques Universitaires de Bruxelles—Hôpital Erasme, 808 Route de Lennik, 1070 Brussels, Belgium
| | - Nazzareno Galiè
- Department of Experimental, Diagnostic and Specialty Medicine, DIMES Alma Mater Studiorum University of Bologna, Via Zamboni, 33 - 40126 Bologna - Partita, Italy
| |
Collapse
|