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Krishtopaytis E, Ampnti SA, Obeidat M, Ramahi N, Lane J, Toth D, Paul D, Tonelli AR. Can Inhaled Nitric Oxide Response Predict Tolerance to Therapies and Survival in Patients With Combined Precapillary and Postcapillary Pulmonary Hypertension? Am J Cardiol 2023; 207:363-369. [PMID: 37778225 DOI: 10.1016/j.amjcard.2023.09.032] [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: 07/20/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 10/03/2023]
Abstract
Inhaled nitric oxide (iNO) relaxes the pulmonary circulation and variably increases the left ventricular preload and pulmonary artery wedge pressure (PAWP)-hemodynamic information that may help guide treatment decisions and assess prognosis in patients with combined precapillary and postcapillary pulmonary hypertension (PH). We included consecutive patients with combined precapillary and postcapillary PH (mean pulmonary artery pressure >20 mm Hg, PAWP >15 mm Hg, and pulmonary vascular resistance [PVR] >2 Woods unit [WU]) who underwent right-sided cardiac catheterization with iNO at the Cleveland Clinic Pulmonary Vascular Disease program between 2017 and 2022. We included 104 patients with baseline PAWP and PVR of 22.2 ± 4.2 mm Hg and 6.1 ± 3.2 WU, respectively. Pulmonary arterial hypertension (PAH) with postcapillary component and PH left heart disease with precapillary component were identified in 27 (26%) and 77 patients (74%), respectively. No side effects were noted during the administration of iNO. During iNO, the PVR decreased 1.1 ± 1.4 WU and the PAWP increased 1.3 ± 3.7 mm Hg. A more pronounced increase in PAWP with iNO was associated with a decrease in PVR (R -0.35, p <0.001) and increase in stroke volume (R 0.20, p = 0.046). Tolerance to PAH-specific medications, overall survival, and heart failure hospitalizations were not significantly associated with the change in PAWP or PVR with iNO. In conclusion, in patients with combined precapillary and postcapillary PH, iNO challenge is safe and caused a significant decrease in PVR, with an increase in PAWP. The changes in PAWP and PVR during iNO administration were not associated with tolerance to PAH-specific medications, heart failure-related hospitalization, or survival.
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Affiliation(s)
| | | | | | - Noor Ramahi
- Departments of Hospital Medicine, Fairview Hospital
| | - James Lane
- Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - David Toth
- Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Deborah Paul
- Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Adriano Roberto Tonelli
- Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio.
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Wiegmann L, Thamsen B, de Zélicourt D, Granegger M, Boës S, Schmid Daners M, Meboldt M, Kurtcuoglu V. Fluid Dynamics in the HeartMate 3: Influence of the Artificial Pulse Feature and Residual Cardiac Pulsation. Artif Organs 2018; 43:363-376. [PMID: 30129977 DOI: 10.1111/aor.13346] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/22/2018] [Accepted: 08/15/2018] [Indexed: 12/17/2022]
Abstract
Ventricular assist devices (VADs), among which the HeartMate 3 (HM3) is the latest clinically approved representative, are often the therapy of choice for patients with end-stage heart failure. Despite advances in the prevention of pump thrombosis, rates of stroke and bleeding remain high. These complications are attributed to the flow field within the VAD, among other factors. One of the HM3's characteristic features is an artificial pulse that changes the rotor speed periodically by 4000 rpm, which is meant to reduce zones of recirculation and stasis. In this study, we investigated the effect of this speed modulation on the flow fields and stresses using high-resolution computational fluid dynamics. To this end, we compared Eulerian and Lagrangian features of the flow fields during constant pump operation, during operation with the artificial pulse feature, and with the effect of the residual native cardiac cycle. We observed good washout in all investigated situations, which may explain the low incidence rates of pump thrombosis. The artificial pulse had no additional benefit on scalar washout performance, but it induced rapid variations in the flow velocity and its gradients. This may be relevant for the removal of deposits in the pump. Overall, we found that viscous stresses in the HM3 were lower than in other current VADs. However, the artificial pulse substantially increased turbulence, and thereby also total stresses, which may contribute to clinically observed issues related to hemocompatibility.
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Affiliation(s)
- Lena Wiegmann
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Bente Thamsen
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Switzerland.,Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Diane de Zélicourt
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Switzerland
| | - Marcus Granegger
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Stefan Boës
- Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Marianne Schmid Daners
- Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Mirko Meboldt
- Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Vartan Kurtcuoglu
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland.,National Center of Competence in Research, Kidney CH, Zurich, Switzerland.,Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
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Warriner DR, Brown AG, Varma S, Sheridan PJ, Lawford P, Hose DR, Al-Mohammad A, Shi Y. Closing the loop: modelling of heart failure progression from health to end-stage using a meta-analysis of left ventricular pressure-volume loops. PLoS One 2014; 9:e114153. [PMID: 25479594 PMCID: PMC4257583 DOI: 10.1371/journal.pone.0114153] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 11/03/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction The American Heart Association (AHA)/American College of Cardiology (ACC) guidelines for the classification of heart failure (HF) are descriptive but lack precise and objective measures which would assist in categorising such patients. Our aim was two fold, firstly to demonstrate quantitatively the progression of HF through each stage using a meta-analysis of existing left ventricular (LV) pressure-volume (PV) loop data and secondly use the LV PV loop data to create stage specific HF models. Methods and Results A literature search yielded 31 papers with PV data, representing over 200 patients in different stages of HF. The raw pressure and volume data were extracted from the papers using a digitising software package and the means were calculated. The data demonstrated that, as HF progressed, stroke volume (SV), ejection fraction (EF%) decreased while LV volumes increased. A 2-element lumped parameter model was employed to model the mean loops and the error was calculated between the loops, demonstrating close fit between the loops. The only parameter that was consistently and statistically different across all the stages was the elastance (Emax). Conclusions For the first time, the authors have created a visual and quantitative representation of the AHA/ACC stages of LVSD-HF, from normal to end-stage. The study demonstrates that robust, load-independent and reproducible parameters, such as elastance, can be used to categorise and model HF, complementing the existing classification. The modelled PV loops establish previously unknown physiological parameters for each AHA/ACC stage of LVSD-HF, such as LV elastance and highlight that it this parameter alone, in lumped parameter models, that determines the severity of HF. Such information will enable cardiovascular modellers with an interest in HF, to create more accurate models of the heart as it fails.
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Affiliation(s)
- David R. Warriner
- Medical Physics Group, Department of Cardiovascular Science, University of Sheffield, Sheffield, S10 2TN, United Kingdom
- Department of Cardiology, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, S5 7AU, United Kingdom
- * E-mail:
| | - Alistair G. Brown
- Medical Physics Group, Department of Cardiovascular Science, University of Sheffield, Sheffield, S10 2TN, United Kingdom
| | - Susheel Varma
- Medical Physics Group, Department of Cardiovascular Science, University of Sheffield, Sheffield, S10 2TN, United Kingdom
| | - Paul J. Sheridan
- Medical Physics Group, Department of Cardiovascular Science, University of Sheffield, Sheffield, S10 2TN, United Kingdom
- Department of Cardiology, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, S5 7AU, United Kingdom
| | - Patricia Lawford
- Medical Physics Group, Department of Cardiovascular Science, University of Sheffield, Sheffield, S10 2TN, United Kingdom
| | - David R. Hose
- Medical Physics Group, Department of Cardiovascular Science, University of Sheffield, Sheffield, S10 2TN, United Kingdom
| | - Abdallah Al-Mohammad
- Department of Cardiology, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, S5 7AU, United Kingdom
| | - Yubing Shi
- Medical Physics Group, Department of Cardiovascular Science, University of Sheffield, Sheffield, S10 2TN, United Kingdom
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Gupta S, Muthiah K, Woldendorp K, Robson D, Jansz P, Hayward CS. Derivation of Indices of Left Ventricular Contractility in the Setting of Continuous-Flow Left Ventricular Assist Device Support. Artif Organs 2014; 38:1029-34. [DOI: 10.1111/aor.12292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sunil Gupta
- Heart Failure and Transplant Unit; St. Vincent's Hospital; Sydney New South Wales Australia
- Faculty of Medicine; The University of New South Wales; Sydney New South Wales Australia
| | - Kavitha Muthiah
- Heart Failure and Transplant Unit; St. Vincent's Hospital; Sydney New South Wales Australia
- Faculty of Medicine; The University of New South Wales; Sydney New South Wales Australia
- Victor Chang Cardiac Research Institute; Sydney New South Wales Australia
| | - Kei Woldendorp
- Heart Failure and Transplant Unit; St. Vincent's Hospital; Sydney New South Wales Australia
- Faculty of Medicine; The University of New South Wales; Sydney New South Wales Australia
| | - Desiree Robson
- Heart Failure and Transplant Unit; St. Vincent's Hospital; Sydney New South Wales Australia
| | - Paul Jansz
- Heart Failure and Transplant Unit; St. Vincent's Hospital; Sydney New South Wales Australia
| | - Christopher S. Hayward
- Heart Failure and Transplant Unit; St. Vincent's Hospital; Sydney New South Wales Australia
- Faculty of Medicine; The University of New South Wales; Sydney New South Wales Australia
- Victor Chang Cardiac Research Institute; Sydney New South Wales Australia
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Boilson BA, Schirger JA, Borlaug BA. Caveat medicus! Pulmonary hypertension in the elderly: a word of caution. Eur J Heart Fail 2010; 12:89-93. [PMID: 20023048 DOI: 10.1093/eurjhf/hfp171] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a common but under-recognized cause of pulmonary hypertension (PH), particularly among the elderly. While elevated pulmonary artery pressures are clearly associated with increased mortality in HFpEF, it remains unknown whether or how pulmonary vascular disease in HFpEF should be treated. This case emphasizes the importance of maintaining a high index of suspicion for HFpEF in elderly patients presenting with PH and illustrates potential hazards associated with selective pulmonary vasodilation in this growing population.
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Affiliation(s)
- Barry A Boilson
- The Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, Rochester, MN 55905, USA
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Mynard J, Penny D, Smolich J. Accurate Automatic Detection of End-Diastole From Left Ventricular Pressure Using Peak Curvature. IEEE Trans Biomed Eng 2008; 55:2651-7. [DOI: 10.1109/tbme.2008.2001295] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Lee WS, Huang WP, Yu WC, Chiou KR, Ding PYA, Chen CH. Estimation of preload recruitable stroke work relationship by a single-beat technique in humans. Am J Physiol Heart Circ Physiol 2003; 284:H744-50. [PMID: 12414443 DOI: 10.1152/ajpheart.00455.2002] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The slope of the preload recruitable stroke work relationship (M(w)) is a highly linear, load-insensitive contractile index. To investigate whether M(w) can be determined from a single steady-state beat, 45 patients were studied during cardiac catheterization. Single-beat M(w) (SBM(w)) was calculated directly from the baseline stroke work and baseline left ventricular (LV) end-diastolic volume (EDV(B)), and the volume-axis intercept (V(w)) was estimated as k x EDV(B) + (k - 1) x LV(wall), where k is the ratio of the epicardial shell volumes corresponding to V(w) and EDV(B) and LV(wall) is the wall volume. The mean of individual k values was 0.72 +/- 0.04, which correlated with LV mass significantly (r = 0.60, P < 0.001). SBM(w) calculated from a constant k of 0.7 predicted M(w) well (r = 0.88, P < 0.0001), and the prediction improved slightly when k was estimated from individual LV mass (r = 0.93, P < 0.0001). Subgroup analyses revealed that the single-beat technique also worked in patients with small or large LV mass or volume or with regional wall motion abnormalities. The absolute change in SBM(w) after dobutamine infusion also correlated with that in M(w). In conclusion, M(w) can be estimated from a steady-state beat without alteration of preload.
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Affiliation(s)
- Wen-Shin Lee
- Division of Cardiology, Taipei Veterans General Hospital, National Yang-Ming University, Taiwan, Republic of China
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Preston IR, Klinger JR, Houtchens J, Nelson D, Mehta S, Hill NS. Pulmonary edema caused by inhaled nitric oxide therapy in two patients with pulmonary hypertension associated with the CREST syndrome. Chest 2002; 121:656-9. [PMID: 11834688 DOI: 10.1378/chest.121.2.656] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is commonly associated with the CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia) syndrome. Inhaled nitric oxide (iNO) is often used to assess acute vasoresponsiveness in patients with PAH, and reports of adverse reactions have been infrequent. We describe two of nine patients with PAH and CREST syndrome who had pulmonary edema develop during acute iNO testing. This complication was not encountered in the 46 patients with other forms of PAH tested with iNO. We suggest that iNO should be used with caution, if at all, to test acute vasoreactivity in patients with CREST syndrome.
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Affiliation(s)
- Ioana R Preston
- Division of Pulmonary, Critical Care and Sleep Medicine, Rhode Island Hospital and Brown University School of Medicine, Providence, RI 02903, USA
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Abstract
Inhaled nitric oxide (INO) allows selective pulmonary vasodilatation with rapidity of action. It is effective in the acute management of reversible pulmonary hypertension in cardiac medical and surgical patients and is also useful in assessing the pulmonary vasodilator capacity in patients with chronic pulmonary hypertension. This review will examine the role of INO in the management of cardiac patients, compared to alternatives where available. The use of INO in cardiac failure, post-operative cardiac patients, patients with congestive cardiac failure or congenital heart disease will also be reviewed. Newer alternatives with prolonged pulmonary activity and simpler administration are also discussed.
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Affiliation(s)
- C S Hayward
- Heart Failure and Transplant Unit, St Vincent's Hospital, Victoria St, Darlinghurst, NSW 2010, Australia.
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