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Giustiniano E, Nisi F, Piccioni F, Gambino F, Aceto R, Lungu R, Carrara A, Neganov M, Cecconi M. Right Ventricle Response to Major Lung Resection (the RIVER Study). J Cardiovasc Echogr 2023; 33:76-82. [PMID: 37772049 PMCID: PMC10529292 DOI: 10.4103/jcecho.jcecho_17_23] [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: 03/17/2023] [Revised: 04/13/2023] [Accepted: 05/21/2023] [Indexed: 09/30/2023] Open
Abstract
Backgrounds Major lung resection is associated with high postoperative morbidity and mortality, especially due to cardiorespiratory complications. Right ventricle (RV) ejection, pulmonary artery (PA) pressure, and tone are tightly coupled. Since the RV is exquisitely sensitive to changes in afterload, an acute increase in RV outflow resistance (i.e., acute pulmonary embolism [PE]) will cause acute RV dilatation and, a reduction of left ventricle compliance too, rapidly spiraling to acute cardiogenic shock and death. We investigated the changing in RV performance after major lung resection. Materials and Methods We carried out transthoracic echocardiography (TTE) aiming at searching for the incidence of early RV systolic dysfunction (defined as tricuspid annulus plane systolic excursion [TAPSE] <17 cm, S'-tissue Doppler imaging <10 cm/s) and estimate the RV-PA coupling by the TAPSE/pulmonary artery pressures (PAPs) ratio after major lung resection. The TTE has been performed before and immediately after surgery. Results After the end of the operation the echocardiographic parameters of the RV function worsened. TAPSE decreased from 24 (21 ÷ 28) to 18 (16 ÷ 22) mm (P = 0.015) and PAPs increased from 26 (25 ÷ 30) to 30 (25 ÷ 39) mmHg (P = 0.013). TAPSE/PAPs ratio decreased from 0.85 (0.80 ÷ 0.90) to 0.64 (0.54 ÷ 0.79) mm/mmHg (P = 0.002). Conclusions In line with previous reports, after major lung resection the increase in afterload reduces the RV function, but the impairment remains clinically not relevant. The different clinical picture of an acute cor pulmonale due to PE implies that the pathogenesis of cardiac failure involves more pathways than the mere mechanic occlusion of the blood flow.
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Affiliation(s)
- Enrico Giustiniano
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Fulvio Nisi
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Federico Piccioni
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Francesco Gambino
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Romina Aceto
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Ramona Lungu
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Alfonso Carrara
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Maxim Neganov
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care, IRCCS, Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Vahdatpour C, Epstein S, Jones K, Smoot M, Parker A, Ryan J, Bryant A. A review of cardio-pulmonary microvascular dysfunction in pulmonary hypertension. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 26:100255. [PMID: 38510189 PMCID: PMC10946046 DOI: 10.1016/j.ahjo.2023.100255] [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: 08/31/2022] [Revised: 01/16/2023] [Accepted: 01/19/2023] [Indexed: 03/22/2024]
Abstract
Microvascular dysfunction progressing to pulmonary hypertension can be a primary cause of right ventricular failure or a secondary cause because of an underlying systemic illness. Little is known regarding the etiology and epidemiology of coronary microvascular dysfunction in pulmonary hypertension. Despite this limitation, its presence has been described in patients with pulmonary hypertension. This review focuses on the pathogenesis of cardiac and pulmonary microvascular dysfunction in pulmonary hypertension. Additionally, this review provides a contemporary assessment on the diagnosis and treatment of microvascular dysfunction in patients in pulmonary hypertension. This topic is important to raise awareness of microvascular dysfunction in the coronary and pulmonary circulation, so that future studies will investigate its impact on the pulmonary hypertension patient cohort.
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Affiliation(s)
- Cyrus Vahdatpour
- Department of Pulmonary Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, USA
| | - Samuel Epstein
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Kirk Jones
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Madeline Smoot
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Alex Parker
- Department of Cardiology, University of Florida, Gainesville, FL, USA
| | - John Ryan
- Department of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, USA
| | - Andrew Bryant
- Department of Pulmonary Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, USA
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Duan A, Li X, Jin Q, Zhang Y, Zhao Z, Zhao Q, Yan L, Huang Z, Hu M, Liu J, An C, Ma X, Xiong C, Luo Q, Liu Z. Prognostic implication of noninvasive right ventricle-to-pulmonary artery coupling in chronic thromboembolic pulmonary hypertension. Ther Adv Chronic Dis 2022; 13:20406223221102803. [PMID: 35757779 PMCID: PMC9218458 DOI: 10.1177/20406223221102803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/28/2022] [Indexed: 11/17/2022] Open
Abstract
Aims: Impairment of right ventricle-to-pulmonary artery coupling (RV-PA coupling) is a major determinant of poor prognosis in patients with pulmonary hypertension. This study sought to evaluate the ability of an echo-derived metric of RV-PA coupling, the ratio between tricuspid annular plane systolic excursion (TAPSE), and pulmonary artery systolic pressure (PASP) and to predict adverse clinical outcomes in chronic thromboembolic pulmonary hypertension (CTEPH). Methods and results: A total of 205 consecutive patients with confirmed CTEPH were retrospectively recruited from Fuwai Hospital between February 2016 and November 2020. Baseline echocardiography, right heart catheterization, and cardiopulmonary exercise testing were analyzed. Patients with lower TAPSE/PASP had a significantly compromised echocardiographic and hemodynamic status and exercise capacity at baseline. The TAPSE/PASP ratio correlated significantly with hemodynamic parameters, including pulmonary vascular resistance (r = −0.48, p < 0.001) and pulmonary arterial compliance (r = 0.45, p < 0.001). During a median period of 1-year follow-up, 63 (30.7%) patients experienced clinical worsening. The relationship between TAPSE/PASP and clinical worsening was assessed using different multivariate Cox regression models. After adjustment for a series of previously screened independent predictors, TAPSE/PASP remained significantly associated with outcomes, and the hazard ratio (per standard deviation increase) of the final model was 0.402. Conclusion: In patients with CTEPH, baseline RV-PA coupling measured as the TAPSE/PASP ratio is associated with disease severity and adverse outcomes. A low TAPSE/PASP identifies patients with a high risk of clinical deterioration, and this novel metric could be applicable for risk stratification in CTEPH.
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Affiliation(s)
- Anqi Duan
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xin Li
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qi Jin
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi Zhang
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhihui Zhao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qing Zhao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lu Yan
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhihua Huang
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Meixi Hu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jiaran Liu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Chenhong An
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiuping Ma
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Changming Xiong
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 Beilishi Rd, Xicheng District, Beijing 100037, China
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 Beilishi Rd, Xicheng District, Beijing 100037, China
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Mooney L, Hawkins NM, Jhund PS, Redfield MM, Vaduganathan M, Desai AS, Rouleau JL, Minamisawa M, Shah AM, Lefkowitz MP, Zile MR, Van Veldhuisen DJ, Pfeffer MA, Anand IS, Maggioni AP, Senni M, Claggett BL, Solomon SD, McMurray JJV. Impact of Chronic Obstructive Pulmonary Disease in Patients With Heart Failure With Preserved Ejection Fraction: Insights From PARAGON-HF. J Am Heart Assoc 2021; 10:e021494. [PMID: 34796742 PMCID: PMC9075384 DOI: 10.1161/jaha.121.021494] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 10/21/2021] [Indexed: 12/12/2022]
Abstract
Background Little is known about the impact of chronic obstructive pulmonary disease (COPD) in patients with heart failure with preserved ejection fraction (HFpEF). Methods and Results We examined outcomes in patients with heart failure with preserved ejection fraction, according to COPD status, in the PARAGON-HF (Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor With Angiotensin Receptor Blocker Global Outcomes in Heart Failure With Preserved Ejection Fraction) trial. The primary outcome was a composite of first and recurrent hospitalizations for heart failure and cardiovascular death. Of 4791 patients, 670 (14%) had COPD. Patients with COPD were more likely to be men (58% versus 47%; P<0.001) and had worse New York Heart Association functional class (class III/IV 24% versus 19%), worse Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores (69 versus 76; P<0.001) and more frequent history of heart failure hospitalization (54% versus 47%; P<0.001). The decrement in Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores with COPD was greater than for other common comorbidities. Patients with COPD had echocardiographic right ventricular enlargement, higher serum creatinine (100 μmol/L versus 96 μmol/L) and neutrophil-to-lymphocyte ratio (2.7 versus 2.5), than those without COPD. After multivariable adjustment, COPD was associated with worse outcomes: adjusted rate ratio for the primary outcome 1.51 (95% CI, 1.25-1.83), total heart failure hospitalization 1.54 (95% CI, 1.24-1.90), cardiovascular death (adjusted hazard ratio [HR], 1.42; 95% CI, 1.10-1.82), and all-cause death (adjusted HR, 1.52; 95% CI, 1.25-1.84). COPD was associated with worse outcomes than other comorbidities and Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores declined more in patients with COPD than in those without. Conclusions Approximately 1 in 7 patients with heart failure with preserved ejection fraction had concomitant COPD, which was associated with greater functional limitation and a higher risk of heart failure hospitalization and death. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01920711.
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Affiliation(s)
- Leanne Mooney
- BHF Glasgow Cardiovascular Research CentreUniversity of GlasgowUnited Kingdom
| | | | - Pardeep S. Jhund
- BHF Glasgow Cardiovascular Research CentreUniversity of GlasgowUnited Kingdom
| | | | | | - Akshay S. Desai
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMA
| | | | | | - Amil M. Shah
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMA
| | | | - Michael R. Zile
- Department of MedicineMedical University of South CarolinaCharlestonSC
| | | | - Marc A. Pfeffer
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMA
| | | | | | - Michele Senni
- Cardiovascular Department & Cardiology UnitPapa Giovanni XXIII HospitalBergamoItaly
| | - Brian L. Claggett
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMA
| | - Scott D. Solomon
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMA
| | - John J. V. McMurray
- BHF Glasgow Cardiovascular Research CentreUniversity of GlasgowUnited Kingdom
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Yuchi Y, Suzuki R, Kanno H, Teshima T, Matsumoto H, Koyama H. Right Ventricular Myocardial Adaptation Assessed by Two-Dimensional Speckle Tracking Echocardiography in Canine Models of Chronic Pulmonary Hypertension. Front Vet Sci 2021; 8:727155. [PMID: 34485446 PMCID: PMC8415444 DOI: 10.3389/fvets.2021.727155] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Pulmonary hypertension (PH) is a life-threatening disease in dogs characterized by an increase in pulmonary arterial pressure (PAP) and/or pulmonary vascular resistance. Right ventricle adapts to its pressure overload through various right ventricular (RV) compensative mechanisms: adaptive and maladaptive remodeling. The former is characterized by concentric hypertrophy and increased compensatory myocardial contractility, whereas the latter is distinguished by eccentric hypertrophy associated with impaired myocardial function. Objectives: To evaluate the RV adaptation associated with the increase of PAP using two-dimensional speckle tracking echocardiography. Animals: Seven experimentally induced PH models. Methods: Dogs were anesthetized and then a pulmonary artery catheter was placed via the right jugular vein. Canine models of PH were induced by the repeated injection of microspheres through the catheter and monitored pulmonary artery pressure. Dogs were performed echocardiography and hemodynamic measurements in a conscious state when baseline and systolic PAP (sPAP) rose to 30, 40, 50 mmHg, and chronic phase. The chronic phase was defined that the sPAP was maintained at 50 mmHg or more for 4 weeks without injection of microspheres. Results: Pulmonary artery to aortic diameter ratio, RV area, end-diastolic RV wall thickness, and RV myocardial performance index were significantly increased in the chronic phase compared with that in the baseline. Tricuspid annular plane systolic excursion was significantly decreased in the chronic phase compared with that in the baseline. The RV longitudinal strain was significantly decreased in the sPAP30 phase, increased in the sPAP40 and sPAP50 phases, and decreased in the chronic phase. Conclusions: Changes in two-dimensional speckle tracking echocardiography-derived RV longitudinal strain might reflect the intrinsic RV myocardial contractility during the PH progression, which could not be detected by conventional echocardiographic parameters.
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Affiliation(s)
- Yunosuke Yuchi
- Laboratory of Veterinary Internal Medicine, Faculty of Veterinary Science, School of Veterinary Medicine, Nippon Veterinary and Life Science University, Musashino, Japan
| | - Ryohei Suzuki
- Laboratory of Veterinary Internal Medicine, Faculty of Veterinary Science, School of Veterinary Medicine, Nippon Veterinary and Life Science University, Musashino, Japan
| | - Haruka Kanno
- Laboratory of Veterinary Internal Medicine, Faculty of Veterinary Science, School of Veterinary Medicine, Nippon Veterinary and Life Science University, Musashino, Japan
| | - Takahiro Teshima
- Laboratory of Veterinary Internal Medicine, Faculty of Veterinary Science, School of Veterinary Medicine, Nippon Veterinary and Life Science University, Musashino, Japan
| | - Hirotaka Matsumoto
- Laboratory of Veterinary Internal Medicine, Faculty of Veterinary Science, School of Veterinary Medicine, Nippon Veterinary and Life Science University, Musashino, Japan
| | - Hidekazu Koyama
- Laboratory of Veterinary Internal Medicine, Faculty of Veterinary Science, School of Veterinary Medicine, Nippon Veterinary and Life Science University, Musashino, Japan
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Vanden Eynden F, El-Oumeiri B, Bové T, Van Nooten G, Segers P. Proximal pressure reducing effect of wave reflection in the pulmonary circulation disappear in obstructive disease: insight from a rabbit model. Am J Physiol Heart Circ Physiol 2019; 316:H992-H1004. [DOI: 10.1152/ajpheart.00635.2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Locating the site of increased resistance within the vascular tree in pulmonary arterial hypertension could assist in both patient diagnosis and tailoring treatment. Wave intensity analysis (WIA) is a wave analysis method that may be capable of localizing the major site of reflection within a vascular system. We investigated the contribution of WIA to the analysis of the pulmonary circulation in a rabbit model with animals subjected to variable occlusive pulmonary disease. Animals were embolized with different sized microspheres for 6 wk ( n = 10) or underwent pulmonary artery (PA) ligation for 6 wk ( n = 3). These animals were compared with a control group ( n = 6) and acutely embolized animals ( n = 4). WIA was performed and compared with impedance-based methods to analyze wave reflections. The control group showed a relatively high extent of reflected waves (15.7 ± 10.6%); reflections had a net effect of pressure reduction during systole, suggesting an open-end reflector. The pattern of wave reflection was not different in the group with partial PA ligation (12.4 ± 4.1%). In the chronically embolized group, wave reflection was not observed (3.6 ± 1.5%). In the acute embolization group, wave reflection was more prominent (37.3 ± 12.6%), with the appearance of a novel wave increasing pressure, suggesting the appearance of a closed-end reflector. Wave reflections of an open-end type are present in the normal rabbit pulmonary circulation. However, the pattern and nature of reflections vary according to the extent of pulmonary vascular occlusion. NEW & NOTEWORTHY The study proposes an original framework of a complementary analysis of wave reflections in the time domain and in the frequency domain. The methodology was used in the pulmonary circulation with different forms of chronic obstructions. The results suggest that the pulmonary vascular tree generates a reflection pattern that could actually assist the heart during ejection, and chronic obstruction significantly modifies the pattern.
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Affiliation(s)
- Frederic Vanden Eynden
- Cardiac Surgery, Université Libre de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium
- Laboratory of Experimental Cardiac Surgery, Ghent University Hospital, Ghent, Belgium
| | - Bachar El-Oumeiri
- Cardiac Surgery, Université Libre de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium
| | - Thierry Bové
- Laboratory of Experimental Cardiac Surgery, Ghent University Hospital, Ghent, Belgium
| | - Guido Van Nooten
- Cardiac Surgery, Université Libre de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium
- Laboratory of Experimental Cardiac Surgery, Ghent University Hospital, Ghent, Belgium
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Effects of Thoracic Epidural Anesthesia on Neuronal Cardiac Regulation and Cardiac Function. Anesthesiology 2019; 130:472-491. [DOI: 10.1097/aln.0000000000002558] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Cardiac sympathetic blockade with high-thoracic epidural anesthesia is considered beneficial in patients undergoing major surgery because it offers protection in ischemic heart disease. Major outcome studies have failed to confirm such a benefit, however. In fact, there is growing concern about potential harm associated with the use of thoracic epidural anesthesia in high-risk patients, although underlying mechanisms have not been identified. Since the latest review on this subject, a number of clinical and experimental studies have provided new information on the complex interaction between thoracic epidural anesthesia–induced sympatholysis and cardiovascular control mechanisms. Perhaps these new insights may help identify conditions in which benefits of thoracic epidural anesthesia may not outweigh potential risks. For example, cardiac sympathectomy with high-thoracic epidural anesthesia decreases right ventricular function and attenuates its capacity to cope with increased right ventricular afterload. Although the clinical significance of this pathophysiologic interaction is unknown at present, it identifies a subgroup of patients with established or pending pulmonary hypertension for whom outcome studies are needed. Other new areas of interest include the impact of thoracic epidural anesthesia–induced sympatholysis on cardiovascular control in conditions associated with increased sympathetic tone, surgical stress, and hemodynamic disruption. It was considered appropriate to collect and analyze all recent scientific information on this subject to provide a comprehensive update on the cardiovascular effects of high-thoracic epidural anesthesia and cardiac sympathectomy in healthy and diseased patients.
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Rana M, Yusuff H, Zochios V. The Right Ventricle During Selective Lung Ventilation for Thoracic Surgery. J Cardiothorac Vasc Anesth 2018; 33:2007-2016. [PMID: 30595486 DOI: 10.1053/j.jvca.2018.11.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Indexed: 12/25/2022]
Abstract
The right ventricle (RV) has been an area of evolving interest after decades of being ignored and considered less important than the left ventricle. Right ventricular dysfunction/failure is an independent predictor of mortality and morbidity in cardiac surgery; however, very little is known about the incidence or impact of RV dysfunction/failure in thoracic surgery. The pathophysiology of RV dysfunction/failure has been studied in the context of acute respiratory distress syndrome (ARDS), cardiac surgery, pulmonary hypertension, and left ventricular failure, but limited data exist in literature addressing the issue of RV dysfunction/failure in the context of thoracic surgery and one-lung ventilation (OLV). Thoracic surgery and OLV present as a unique situation where the RV is faced with sudden changes in afterload, preload, and contractility throughout the perioperative period. The authors discuss the possible pathophysiologic mechanisms that can affect adversely the RV during OLV and introduce the term RV injury to the myocardium that is affected adversely by the various intraoperative factors, which then makes it predisposed to acute dysfunction. The most important of these mechanisms seems to be the role of intraoperative mechanical ventilation, which potentially could cause both ventilator-induced lung injury leading to ARDS and RV injury. Identification of at-risk patients in the perioperative period using focused imaging, particularly echocardiography, is paramount. The authors also discuss the various RV-protective strategies required to prevent RV dysfunction and management of established RV failure.
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Affiliation(s)
- Meenal Rana
- University Hospitals of Leicester National Health Service Trust, Department of Cardiothoracic Anesthesia and Critical Care Medicine, Glenfield Hospital, Leicester, UK; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK
| | - Hakeem Yusuff
- University Hospitals of Leicester National Health Service Trust, Department of Cardiothoracic Anesthesia and Critical Care Medicine, Glenfield Hospital, Leicester, UK; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK.
| | - Vasileios Zochios
- University Hospitals Birmingham National Health Service Foundation Trust, Department of Critical Care Medicine, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK
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9
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Does Nasal Surgery Affect Right Ventricular Myocardial Functions at the Tissue Level in Patients with Nasal Septum Deviation? J Clin Med 2018; 7:jcm7080186. [PMID: 30060456 PMCID: PMC6112028 DOI: 10.3390/jcm7080186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 07/18/2018] [Accepted: 07/23/2018] [Indexed: 01/20/2023] Open
Abstract
Objective: One of the most common causes of upper airway obstruction in adults is nasal septum deviation (NSD). The chronic hypoxia caused by this obstruction gradually leads to increased pulmonary vascular resistance, pulmonary hypertension (PHT), and right ventricular (RV) failure. The purpose of this study was to determine changes in RV myocardial functions at the tissue level before, and after surgery in patients with NSD. Subjects and Methods: Fifty-eight patients with symptoms of nasal obstruction and snoring were included in this observational study. Preoperative and postoperative third-month peripheral arterial oxygen saturation (SpO2), and RV systolic and diastolic functions measured by pulmonary artery systolic pressure (PASP), tissue Doppler parameters, and speckle tracking echocardiography (STE) were studied in these patients. Results: We observed a very significant decrease in PASP in the postoperative period (32.54 ± 5.24 mmHg vs. 24.22 ± 4.55 mmHg, p = 0.001). Postoperative SpO2 values, measured at room temperature also increased significantly (93.5 ± 0.82% vs. 95.6 ± 0.79%, p = 0.001). There was a significant improvement after surgery in RV systolic functions, represented by global longitudinal strain (GLS) (21.12 ± 2.07 vs. 22.49 ± 1.89, p = 0.013) and systolic global longitudinal strain rate (GLSRs) (1.30 ± 0.12 vs. 1.38 ± 0.13, p = 0.015). No significant differences in terms of RV diastolic function parameters were detected, including the RV early diastolic global longitudinal strain rate (GLSRe) (1.56 ± 0.21 vs. 1.55 ± 0.26, p = 0.86) and RV late diastolic global longitudinal strain rate (GLSRa) (0.88 ± 0.19; 0.89 ± 0.18, p = 0.76). Conclusion: This study was performed with an advanced technique capable of tissue level examination. The findings demonstrated significant improvement in both chronic hypoxia and RV systolic myocardial functions, measured at the tissue level after nasal surgery.
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Mercurio V, Palazzuoli A, Correale M, Lombardi C, Passantino A, Ravera A, Ruocco G, Sciatti E, Triggiani M, Lagioia R, Scrutinio D, Tocchetti CG, Nodari S. Right heart dysfunction: from pathophysiologic insights to therapeutic options: a translational overview. J Cardiovasc Med (Hagerstown) 2018; 19:613-623. [PMID: 30048301 DOI: 10.2459/jcm.0000000000000700] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
: The right ventricle has become increasingly studied in cardiovascular research. In this article, we describe specific pathophysiological characteristics of the right ventricle, with special focus on functional and molecular modifications as well as therapeutic strategies in right ventricular dysfunction, underlining the differences with the left ventricle. Then we analyze the main imaging modalities to assess right ventricular function in different clinical settings. Finally, we acknowledge main therapeutic advances for treatment of right heart diseases.
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Affiliation(s)
- Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples
| | - Alberto Palazzuoli
- Department of Internal Medicine, Cardiovascular Diseases Unit, University of Siena, Siena
| | | | - Carlo Lombardi
- Cardiology Section, Department of Clinical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia
| | - Andrea Passantino
- Istituti Clinici Scientifici Maugeri. Istituto di Cassano delle Murge. I.R.C.C.S., Cassano Murge, Bari, Italy
| | - Alice Ravera
- Cardiology Section, Department of Clinical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia
| | - Gaetano Ruocco
- Department of Internal Medicine, Cardiovascular Diseases Unit, University of Siena, Siena
| | - Edoardo Sciatti
- Cardiology Section, Department of Clinical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia
| | - Marco Triggiani
- Cardiology Section, Department of Clinical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia
| | - Rocco Lagioia
- Istituti Clinici Scientifici Maugeri. Istituto di Cassano delle Murge. I.R.C.C.S., Cassano Murge, Bari, Italy
| | - Domenico Scrutinio
- Istituti Clinici Scientifici Maugeri. Istituto di Cassano delle Murge. I.R.C.C.S., Cassano Murge, Bari, Italy
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples
| | - Savina Nodari
- Cardiology Section, Department of Clinical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia
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11
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Tabima DM, Philip JL, Chesler NC. Right Ventricular-Pulmonary Vascular Interactions. Physiology (Bethesda) 2018; 32:346-356. [PMID: 28814495 DOI: 10.1152/physiol.00040.2016] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 06/16/2017] [Accepted: 07/06/2017] [Indexed: 11/22/2022] Open
Abstract
Accurate and comprehensive evaluation of right ventricular (RV)-pulmonary vascular (PV) interactions is critical to the assessment of cardiopulmonary function, dysfunction, and failure. Here, we review methods of quantifying RV-PV interactions and experimental results from clinical trials as well as large- and small-animal models based on pressure-volume analysis. We conclude by outlining critical gaps in knowledge that should drive future studies.
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Affiliation(s)
- Diana M Tabima
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, Wisconsin; and
| | - Jennifer L Philip
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, Wisconsin; and.,Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| | - Naomi C Chesler
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, Wisconsin; and
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12
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Jaijee S, Quinlan M, Tokarczuk P, Clemence M, Howard LSGE, Gibbs JSR, O'Regan DP. Exercise cardiac MRI unmasks right ventricular dysfunction in acute hypoxia and chronic pulmonary arterial hypertension. Am J Physiol Heart Circ Physiol 2018; 315:H950-H957. [PMID: 29775415 PMCID: PMC6230906 DOI: 10.1152/ajpheart.00146.2018] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Coupling of right ventricular (RV) contractility to afterload is maintained at rest in the early stages of pulmonary arterial hypertension (PAH), but exercise may unmask depleted contractile reserves. We assessed whether elevated afterload reduces RV contractile reserve despite compensated resting function using noninvasive exercise imaging. Fourteen patients with PAH (mean age: 39.1 yr, 10 women and 4 men) and 34 healthy control subjects (mean ageL 35.6 yr, 17 women and 17 men) completed real-time cardiac magnetic resonance imaging during submaximal exercise breathing room air. Control subjects were then also exercised during acute normobaric hypoxia (fraction of inspired O2: 12%). RV contractile reserve was assessed by the effect of exercise on ejection fraction. In control subjects, the increase in RV ejection fraction on exercise was less during hypoxia (P = 0.017), but the response of left ventricular ejection fraction to exercise did not change. Patients with PAH had an impaired RV reserve, with half demonstrating a fall in RV ejection fraction on exercise despite comparable resting function to controls (PAH: rest 53.6 ± 4.3% vs. exercise 51.4 ± 10.7%; controls: rest 57.1 ± 5.2% vs. exercise 69.6 ± 6.1%, P < 0.0001). In control subjects, the increase in stroke volume index on exercise was driven by reduced RV end-systolic volume, whereas patients with PAH did not augment the stroke volume index, with increases in both end-diastolic and end-systolic volumes. From baseline hemodynamic and exercise capacity variables, only the minute ventilation-to-CO2 output ratio was an independent predictor of RV functional reserve (P = 0.021). In conclusion, noninvasive cardiac imaging during exercise unmasks depleted RV contractile reserves in healthy adults under hypoxic conditions and patients with PAH under normoxic conditions despite preserved ejection fraction at rest. NEW & NOTEWORTHY Right ventricular (RV) reserve was assessed using real-time cardiac magnetic resonance imaging in patients with pulmonary arterial hypertension and in healthy control subjects under normobaric hypoxia, which has been previously associated with acute pulmonary hypertension. Hypoxia caused a mild reduction in RV reserve, whereas chronic pulmonary arterial hypertension was associated with a marked reduction in RV reserve.
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Affiliation(s)
- Shareen Jaijee
- MRC London Institute of Medical Sciences, Imperial College London , London , United Kingdom
| | - Marina Quinlan
- MRC London Institute of Medical Sciences, Imperial College London , London , United Kingdom
| | - Pawel Tokarczuk
- MRC London Institute of Medical Sciences, Imperial College London , London , United Kingdom
| | | | - Luke S G E Howard
- Department of Cardiology, National Pulmonary Hypertension Service, Imperial College Healthcare NHS Trust , London , United Kingdom
| | - J Simon R Gibbs
- Department of Cardiology, National Pulmonary Hypertension Service, Imperial College Healthcare NHS Trust , London , United Kingdom.,National Heart and Lung Institute, Imperial College London , London , United Kingdom
| | - Declan P O'Regan
- MRC London Institute of Medical Sciences, Imperial College London , London , United Kingdom
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13
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Boehm M, Lawrie A, Wilhelm J, Ghofrani HA, Grimminger F, Weissmann N, Seeger W, Schermuly RT, Kojonazarov B. Maintained right ventricular pressure overload induces ventricular-arterial decoupling in mice. Exp Physiol 2018; 102:180-189. [PMID: 27990701 DOI: 10.1113/ep085963] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 11/28/2016] [Indexed: 12/14/2022]
Abstract
NEW FINDINGS What is the central question of this study? The aim was to investigate whether complementary assessment of non-invasive ultrasound imaging together with closed chest-derived intracardiac pressure-volume catheterization is applicable to mice for an in-depth characterization of right ventricular (RV) function even upon maintained pressure overload. What is the main finding and its importance? Characterization of RV function by the complementary use of echocardiographic imaging together with pressure-volume catheterization reveals ventricular-arterial decoupling upon maintained pressure overload, where RV systolic function correlates with ventricular-arterial coupling rather than contractility, whereas diastolic function correlates well with RV diastolic pressure. This combined approach allows us to phenotype RV function and dysfunction better in genetically modified and/or pharmacologically treated mice. Assessment of right ventricular (RV) function in rodents is a challenge because of the complex RV anatomy and structure. To date, the best characterization of RV function has been achieved by accurate cardiovascular phenotyping, involving a combination of non-invasive imaging and intracardiac pressure-volume measurements. We sought to investigate the feasibility of two complementary phenotyping techniques for the evaluation of RV function in an experimental mouse model of sustained RV pressure overload. Mice underwent either sham surgery (n = 5) or pulmonary artery banding (n = 8) to induce isolated RV pressure overload. After 3 weeks, indices of RV function were assessed by echocardiography (Vevo2100) and closed chest-derived invasive pressure-volume measurements (PVR-1030). Pulmonary artery banding resulted in RV hypertrophy and dilatation accompanied by systolic and diastolic dysfunction. Invasive RV haemodynamic measurements demonstrated an increased end-systolic elastance and arterial elastance after pulmonary artery banding compared with sham operation, resulting in ventricular-arterial decoupling. Regression analysis revealed that tricuspid annular plane systolic excursion is correlated with ventricular-arterial coupling (r² = 0.77, P = 0.002) rather than with RV contractility (r² = -0.61, P = 0.07). Furthermore, the isovolumic relaxation time to ECG-derived R-R interval and the ratio of the early diastolic peak velocity measured by pulsed wave Doppler to the early diastolic peak obtained during tissue Doppler imaging correlate well with RV end-diastolic pressure (r² = 0.87, P = 0.0001 and r² = 0.82, P = 0.0009, respectively). Commonly used indices of systolic RV function are associated with RV-arterial coupling rather than contractility, whereas diastolic indices well correlate with end-diastolic pressure when there is maintained pressure overload.
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Affiliation(s)
- Mario Boehm
- Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardio-Pulmonary System (ECCPS), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Allan Lawrie
- Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany
| | - Jochen Wilhelm
- Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardio-Pulmonary System (ECCPS), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Hossein A Ghofrani
- Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardio-Pulmonary System (ECCPS), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Friedrich Grimminger
- Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardio-Pulmonary System (ECCPS), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Norbert Weissmann
- Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardio-Pulmonary System (ECCPS), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- Pulmonary Vascular Research Group, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Ralph T Schermuly
- Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardio-Pulmonary System (ECCPS), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Baktybek Kojonazarov
- Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardio-Pulmonary System (ECCPS), Member of the German Center for Lung Research (DZL), Giessen, Germany
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14
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Acute Right Ventricular Dysfunction in Intensive Care Unit. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8217105. [PMID: 29201914 PMCID: PMC5671685 DOI: 10.1155/2017/8217105] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/13/2017] [Accepted: 09/18/2017] [Indexed: 02/07/2023]
Abstract
The role of the left ventricle in ICU patients with circulatory shock has long been considered. However, acute right ventricle (RV) dysfunction causes and aggravates many common critical diseases (acute respiratory distress syndrome, pulmonary embolism, acute myocardial infarction, and postoperative cardiac surgery). Several supportive therapies, including mechanical ventilation and fluid management, can make RV dysfunction worse, potentially exacerbating shock. We briefly review the epidemiology, pathophysiology, diagnosis, and recommendations to guide management of acute RV dysfunction in ICU patients. Our aim is to clarify the complex effects of mechanical ventilation, fluid therapy, vasoactive drug infusions, and other therapies to resuscitate the critical patient optimally.
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15
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Bellofiore A, Vanderpool R, Brewis MJ, Peacock AJ, Chesler NC. A novel single-beat approach to assess right ventricular systolic function. J Appl Physiol (1985) 2017; 124:283-290. [PMID: 29025899 DOI: 10.1152/japplphysiol.00258.2017] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Clinical assessment of right ventricular (RV) contractility in diseases such as pulmonary arterial hypertension (PAH) has been hindered by the lack of a robust methodology. Here, a novel, clinically viable, single-beat method was developed to assess end-systolic elastance (Ees), a measure of right ventricular (RV) contractility. We hypothesized that this novel approach reduces uncertainty and interobserver variability in the estimation of the maximum isovolumic pressure (Piso), the key step in single-beat methods. The new method was designed to include a larger portion of the RV pressure data and minimize subjective adjustments by the operator. Data were obtained from right heart catheterization of PAH patients in a multicenter prospective study ( data set 1) and a single-center retrospective study ( data set 2). To obtain Piso, three independent observers used an established single-beat method (based on the first derivative of the pressure waveform) and the novel method (based on the second derivative). Interobserver variability analysis included paired t-test, one-way ANOVA, interclass correlation (ICC) analysis, and a modified Bland-Altman analysis. The Piso values obtained from the two methods were linearly correlated for both data set 1 ( R2 = 0.74) and data set 2 ( R2 = 0.91). Compared with the established method, the novel method resulted in smaller interobserver variability ( P < 0.001), nonsignificant differences between observers, and a narrower confidence interval. By reducing uncertainty and interobserved variability, this novel approach may pave the way for more effective clinical management of PAH. NEW & NOTEWORTHY A novel methodology to assess right ventricular contractility from clinical data is demonstrated. This approach significantly reduces interobserver variability in the analysis of ventricular pressure data, as demonstrated in a relatively large population of subjects with pulmonary hypertension. This study may enable more accurate clinical monitoring of systolic function in subjects with pulmonary hypertension.
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Affiliation(s)
- Alessandro Bellofiore
- Department of Biomedical, Chemical and Materials Engineering, San Jose State University , San Jose, California.,Department of Biomedical Engineering, University of Wisconsin-Madison , Madison, Wisconsin
| | - Rebecca Vanderpool
- Vascular Medicine Institute, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Melanie J Brewis
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital , Glasgow , United Kingdom
| | - Andrew J Peacock
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital , Glasgow , United Kingdom
| | - Naomi C Chesler
- Department of Biomedical Engineering, University of Wisconsin-Madison , Madison, Wisconsin.,Department of Medicine, University of Wisconsin-Madison , Madison, Wisconsin
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16
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Kylhammar D, Rådegran G. The principal pathways involved in the in vivo modulation of hypoxic pulmonary vasoconstriction, pulmonary arterial remodelling and pulmonary hypertension. Acta Physiol (Oxf) 2017; 219:728-756. [PMID: 27381367 DOI: 10.1111/apha.12749] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 06/10/2016] [Accepted: 07/04/2016] [Indexed: 12/13/2022]
Abstract
Hypoxic pulmonary vasoconstriction (HPV) serves to optimize ventilation-perfusion matching in focal hypoxia and thereby enhances pulmonary gas exchange. During global hypoxia, however, HPV induces general pulmonary vasoconstriction, which may lead to pulmonary hypertension (PH), impaired exercise capacity, right-heart failure and pulmonary oedema at high altitude. In chronic hypoxia, generalized HPV together with hypoxic pulmonary arterial remodelling, contribute to the development of PH. The present article reviews the principal pathways in the in vivo modulation of HPV, hypoxic pulmonary arterial remodelling and PH with primary focus on the endothelin-1, nitric oxide, cyclooxygenase and adenine nucleotide pathways. In summary, endothelin-1 and thromboxane A2 may enhance, whereas nitric oxide and prostacyclin may moderate, HPV as well as hypoxic pulmonary arterial remodelling and PH. The production of prostacyclin seems to be coupled primarily to cyclooxygenase-1 in acute hypoxia, but to cyclooxygenase-2 in chronic hypoxia. The potential role of adenine nucleotides in modulating HPV is unclear, but warrants further study. Additional modulators of the pulmonary vascular responses to hypoxia may include angiotensin II, histamine, serotonin/5-hydroxytryptamine, leukotrienes and epoxyeicosatrienoic acids. Drugs targeting these pathways may reduce acute and/or chronic hypoxic PH. Endothelin receptor antagonists and phosphodiesterase-5 inhibitors may additionally improve exercise capacity in hypoxia. Importantly, the modulation of the pulmonary vascular responses to hypoxia varies between species and individuals, with hypoxic duration and age. The review also define how drugs targeting the endothelin-1, nitric oxide, cyclooxygenase and adenine nucleotide pathways may improve pulmonary haemodynamics, but also impair pulmonary gas exchange by interference with HPV in chronic lung diseases.
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Affiliation(s)
- D. Kylhammar
- Department of Clinical Sciences Lund, Cardiology; Faculty of Medicine; Lund University; Lund Sweden
- The Section for Heart Failure and Valvular Disease; VO Heart and Lung Medicine; Skåne University Hospital; Lund Sweden
| | - G. Rådegran
- Department of Clinical Sciences Lund, Cardiology; Faculty of Medicine; Lund University; Lund Sweden
- The Section for Heart Failure and Valvular Disease; VO Heart and Lung Medicine; Skåne University Hospital; Lund Sweden
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17
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Golob MJ, Tabima DM, Wolf GD, Johnston JL, Forouzan O, Mulchrone AM, Kellihan HB, Bates ML, Chesler NC. Pulmonary arterial strain- and remodeling-induced stiffening are differentiated in a chronic model of pulmonary hypertension. J Biomech 2017; 55:92-98. [PMID: 28262286 DOI: 10.1016/j.jbiomech.2017.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/30/2017] [Accepted: 02/11/2017] [Indexed: 02/06/2023]
Abstract
Pulmonary hypertension (PH) is a debilitating vascular disease that leads to pulmonary artery (PA) stiffening, which is a predictor of patient mortality. During PH development, PA stiffening adversely affects right ventricular function. PA stiffening has been investigated through the arterial nonlinear elastic response during mechanical testing using a canine PH model. However, only circumferential properties were reported and in the absence of chronic PH-induced PA remodeling. Remodeling can alter arterial nonlinear elastic properties via chronic changes in extracellular matrix (ECM) content and geometry. Here, we used an established constitutive model to demonstrate and differentiate between strain-stiffening, which is due to nonlinear elasticity, and remodeling-induced stiffening, which is due to ECM and geometric changes, in a canine model of chronic thromboembolic PH (CTEPH). To do this, circumferential and axial tissue strips of large extralobar PAs from control and CTEPH tissues were tested in uniaxial tension, and data were fit to a phenomenological constitutive model. Strain-induced stiffening was evident from mechanical testing as nonlinear elasticity in both directions and computationally by a high correlation coefficient between the mechanical data and model (R2=0.89). Remodeling-induced stiffening was evident from a significant increase in the constitutive model stress parameter, which correlated with increased PA collagen content and decreased PA elastin content as measured histologically. The ability to differentiate between strain- and remodeling-induced stiffening in vivo may lead to tailored clinical treatments for PA stiffening in PH patients.
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Affiliation(s)
- Mark J Golob
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, WI 53706, United States
| | - Diana M Tabima
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, WI 53706, United States
| | - Gregory D Wolf
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, WI 53706, United States
| | - James L Johnston
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, WI 53706, United States
| | - Omid Forouzan
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, WI 53706, United States
| | - Ashley M Mulchrone
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, WI 53706, United States
| | - Heidi B Kellihan
- Department of Veterinary Medicine, University of Wisconsin-Madison, Madison, WI 53706, United States
| | - Melissa L Bates
- Department of Physiology, University of Iowa, Iowa City, IA 52242, United States
| | - Naomi C Chesler
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, WI 53706, United States.
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18
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Knai K, Skjaervold NK. A pig model of acute right ventricular afterload increase by hypoxic pulmonary vasoconstriction. BMC Res Notes 2017; 10:2. [PMID: 28057053 PMCID: PMC5217654 DOI: 10.1186/s13104-016-2333-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 12/10/2016] [Indexed: 12/20/2022] Open
Abstract
Background The aim of this study was to construct a non-invasive model for acute right ventricular afterload increase by hypoxic pulmonary vasoconstriction. Intact animal models are vital to improving our understanding of the pathophysiology of acute right ventricular failure. Acute right ventricular failure is caused by increased afterload of the right ventricle by chronic or acute pulmonary hypertension combined with regionally or globally reduced right ventricular contractile capacity. Previous models are hampered by their invasiveness; this is unfortunate as the pulmonary circulation is a low-pressure system that needs to be studied in closed chest animals. Hypoxic pulmonary vasoconstriction is a mechanism that causes vasoconstriction in alveolar vessels in response to alveolar hypoxia. In this study we explored the use of hypoxic pulmonary vasoconstriction as a means to increase the pressure load on the right ventricle. Results Pulmonary hypertension was induced by lowering the FiO2 to levels below the physiological range in eight anesthetized and mechanically ventilated pigs. The pigs were monitored with blood pressure measurements and blood gases. The mean pulmonary artery pressures (mPAP) of the animals increased from 18.3 (4.2) to 28.4 (4.6) mmHg and the pulmonary vascular resistance (PVR) from 254 (76) dyns/cm5 to 504 (191) dyns/cm5, with a lowering of FiO2 from 0.30 to 0.15 (0.024). The animals’ individual baseline mPAPs varied substantially as did their response to hypoxia. The reduced FiO2 level yielded an overall lowering in oxygen offer, but the global oxygen consumption was unaltered. Conclusions We showed in this study that the mPAP and the PVR could be raised by approximately 100% in the study animals by lowering the FiO2 from 0.30 to 0.15 (0.024). We therefore present a novel method for minimally invasive (closed chest) right ventricular afterload manipulations intended for future studies of acute right ventricular failure. The method should in theory be reversible, although this was not studied in this work. Electronic supplementary material The online version of this article (doi:10.1186/s13104-016-2333-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kathrine Knai
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Nils Kristian Skjaervold
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Anaesthesia and Intensive Care Medicine, Trondheim University Hospital, Trondheim, Norway
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19
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Wink J, de Wilde RBP, Wouters PF, van Dorp ELA, Veering BT, Versteegh MIM, Aarts LPHJ, Steendijk P. Thoracic Epidural Anesthesia Reduces Right Ventricular Systolic Function With Maintained Ventricular-Pulmonary Coupling. Circulation 2016; 134:1163-1175. [DOI: 10.1161/circulationaha.116.022415] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 09/02/2016] [Indexed: 11/16/2022]
Abstract
Background:
Blockade of cardiac sympathetic fibers by thoracic epidural anesthesia may affect right ventricular function and interfere with the coupling between right ventricular function and right ventricular afterload. Our main objectives were to study the effects of thoracic epidural anesthesia on right ventricular function and ventricular-pulmonary coupling.
Methods:
In 10 patients scheduled for lung resection, right ventricular function and its response to increased afterload, induced by temporary, unilateral clamping of the pulmonary artery, was tested before and after induction of thoracic epidural anesthesia using combined pressure-conductance catheters.
Results:
Thoracic epidural anesthesia resulted in a significant decrease in right ventricular contractility (ΔESV
25
: +25.5 mL,
P
=0.0003; ΔEes: -0.025 mm Hg/mL,
P
=0.04). Stroke work, dP/dt
MAX
, and ejection fraction showed a similar decrease in systolic function (all
P
<0.05). A concomitant decrease in effective arterial elastance (ΔEa: -0.094 mm Hg/mL,
P
=0.004) yielded unchanged ventricular-pulmonary coupling. Cardiac output, systemic vascular resistance, and mean arterial blood pressure were unchanged. Clamping of the pulmonary artery significantly increased afterload (ΔEa: +0.226 mm Hg/mL,
P
<0.001). In response, right ventricular contractility increased (ΔESV
25
: -26.6 mL,
P
=0.0002; ΔEes: +0.034 mm Hg/mL,
P
=0.008), but ventricular-pulmonary coupling decreased (Δ(Ees/Ea) = -0.153,
P
<0.0001). None of the measured indices showed significant interactive effects, indicating that the effects of increased afterload were the same before and after thoracic epidural anesthesia.
Conclusions:
Thoracic epidural anesthesia impairs right ventricular contractility but does not inhibit the native positive inotropic response of the right ventricle to increased afterload. Right ventricular-pulmonary arterial coupling was decreased with increased afterload but not affected by the induction of thoracic epidural anesthesia.
Clinical Trial Registration:
URL:
http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2844
. Unique identifier: NTR2844.
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Affiliation(s)
- Jeroen Wink
- From the Department of Anesthesiology (J.W., E.L.A.v.D., B.T.V., L.P.H.J.A.), Department of Intensive Care (R.B.P.d.W.), Department of Cardiothoracic Surgery (M.I.M.V.), and Department of Cardiology (P.S.), Leiden University Medical Center, The Netherlands; and the Department of Anesthesia, University Hospitals Ghent, Belgium (P.F.W.)
| | - Rob B. P. de Wilde
- From the Department of Anesthesiology (J.W., E.L.A.v.D., B.T.V., L.P.H.J.A.), Department of Intensive Care (R.B.P.d.W.), Department of Cardiothoracic Surgery (M.I.M.V.), and Department of Cardiology (P.S.), Leiden University Medical Center, The Netherlands; and the Department of Anesthesia, University Hospitals Ghent, Belgium (P.F.W.)
| | - Patrick F. Wouters
- From the Department of Anesthesiology (J.W., E.L.A.v.D., B.T.V., L.P.H.J.A.), Department of Intensive Care (R.B.P.d.W.), Department of Cardiothoracic Surgery (M.I.M.V.), and Department of Cardiology (P.S.), Leiden University Medical Center, The Netherlands; and the Department of Anesthesia, University Hospitals Ghent, Belgium (P.F.W.)
| | - Eveline L. A. van Dorp
- From the Department of Anesthesiology (J.W., E.L.A.v.D., B.T.V., L.P.H.J.A.), Department of Intensive Care (R.B.P.d.W.), Department of Cardiothoracic Surgery (M.I.M.V.), and Department of Cardiology (P.S.), Leiden University Medical Center, The Netherlands; and the Department of Anesthesia, University Hospitals Ghent, Belgium (P.F.W.)
| | - Bernadette Th. Veering
- From the Department of Anesthesiology (J.W., E.L.A.v.D., B.T.V., L.P.H.J.A.), Department of Intensive Care (R.B.P.d.W.), Department of Cardiothoracic Surgery (M.I.M.V.), and Department of Cardiology (P.S.), Leiden University Medical Center, The Netherlands; and the Department of Anesthesia, University Hospitals Ghent, Belgium (P.F.W.)
| | - Michel I. M. Versteegh
- From the Department of Anesthesiology (J.W., E.L.A.v.D., B.T.V., L.P.H.J.A.), Department of Intensive Care (R.B.P.d.W.), Department of Cardiothoracic Surgery (M.I.M.V.), and Department of Cardiology (P.S.), Leiden University Medical Center, The Netherlands; and the Department of Anesthesia, University Hospitals Ghent, Belgium (P.F.W.)
| | - Leon P. H. J. Aarts
- From the Department of Anesthesiology (J.W., E.L.A.v.D., B.T.V., L.P.H.J.A.), Department of Intensive Care (R.B.P.d.W.), Department of Cardiothoracic Surgery (M.I.M.V.), and Department of Cardiology (P.S.), Leiden University Medical Center, The Netherlands; and the Department of Anesthesia, University Hospitals Ghent, Belgium (P.F.W.)
| | - Paul Steendijk
- From the Department of Anesthesiology (J.W., E.L.A.v.D., B.T.V., L.P.H.J.A.), Department of Intensive Care (R.B.P.d.W.), Department of Cardiothoracic Surgery (M.I.M.V.), and Department of Cardiology (P.S.), Leiden University Medical Center, The Netherlands; and the Department of Anesthesia, University Hospitals Ghent, Belgium (P.F.W.)
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20
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Cheyne WS, Williams AM, Harper MI, Eves ND. Heart-lung interaction in a model of COPD: importance of lung volume and direct ventricular interaction. Am J Physiol Heart Circ Physiol 2016; 311:H1367-H1374. [PMID: 27765746 DOI: 10.1152/ajpheart.00458.2016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 10/03/2016] [Indexed: 01/29/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is associated with dynamic lung hyperinflation (DH), increased pulmonary vascular resistance (PVR), and large increases in negative intrathoracic pressure (nITP). The individual and interactive effect of these stressors on left ventricular (LV) filling, emptying, and geometry and the role of direct ventricular interaction (DVI) in mediating these interactions have not been fully elucidated. Twenty healthy subjects were exposed to the following stressors alone and in combination: 1) inspiratory resistive loading of -20 cmH2O (nITP), 2) expiratory resistive loading to cause dynamic hyperinflation (DH), and 3) normobaric-hypoxia to increase PVR (hPVR). LV volumes and geometry were assessed using triplane echocardiography. LV stroke volume (LVSV) was reduced during nITP by 7 ± 7% (mean ± SD; P < 0.001) through a 4 ± 5% reduction in LV end-diastolic volume (LVEDV) (P = 0.002), while DH reduced LVSV by 12 ± 13% (P = 0.001) due to a 9 ± 10% reduction in LVEDV (P < 0.001). The combination of nITP and DH (nITP+DH) caused larger reductions in LVSV (16 ± 16%, P < 0.001) and LVEDV (12 ± 10%, P < 0.001) than nITP alone (P < 0.05). The addition of hPVR to nITP+DH did not further reduce LV volumes. Significant septal flattening (indicating DVI) occurred in all conditions, with a significantly greater leftward septal shift occurring with nITP+DH than either condition alone (P < 0.05). In summary, the interaction of nITP and DH reduces LV filling through DVI. However, DH may be more detrimental to LV hemodynamics than nITP, likely due to mediastinal constraint of the heart amplifying DVI.
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Affiliation(s)
- William S Cheyne
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - Alexandra M Williams
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - Megan I Harper
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - Neil D Eves
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
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21
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Yin X, Wang L, Qin G, Luo H, Liu X, Zhang F, Ye Z, Zhang J, Wang E. Rats with Chronic, Stable Pulmonary Hypertension Tolerate Low Dose Sevoflurane Inhalation as Well as Normal Rats Do. PLoS One 2016; 11:e0154154. [PMID: 27144451 PMCID: PMC4856326 DOI: 10.1371/journal.pone.0154154] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 04/08/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The effects of low concentration of sevoflurane on right ventricular (RV) function and intracellular calcium in the setting of pulmonary arterial hypertension (PAH) have not been investigated clearly. We aim to study these effects and associated signaling pathways in rats with PAH. METHODS Hemodynamics were assessed with or without sevoflurane inhalation in established PAH rats. We analysis the classic RV function parameters and RV-PA coupling efficiency using steady-state PV loop recordings. The protein levels of SERCA2, PLB and p-PLB expression was analyzed by western blot to assess their relevance in PAH. RESULTS Rats with PAH presented with RV hypertrophy and increased pulmonary arterial pressure. The values of Ea, R/L ratio, ESP, SW, PRSW, +dP/dtmax and the slope of the dP/dtmax-EDV relationship increased significantly in PAH rats (P<0.05). Sevoflurane induced a concentration-dependent decrease of systemic and pulmonary blood pressure, HR, RV contractility, and increased the R/L ratio in both groups. Sevoflurane reduced the expression of SERCA2 and increased the expression of PLB in both groups. Interestingly, sevoflurane only reduced the p-PLB/PLB ratio in PAH rats, not in normal rats. CONCLUSIONS Rats with chronic, stable pulmonary hypertension tolerate low concentrations of sevoflurane inhalation as well as normal rats do. It may be related to the modulation of the SERCA2-PLB signaling pathway.
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MESH Headings
- Administration, Inhalation
- Animals
- Calcium-Binding Proteins/metabolism
- Familial Primary Pulmonary Hypertension/drug therapy
- Familial Primary Pulmonary Hypertension/metabolism
- Familial Primary Pulmonary Hypertension/physiopathology
- Hemodynamics/drug effects
- Hemodynamics/physiology
- Hypertension, Pulmonary/drug therapy
- Hypertension, Pulmonary/metabolism
- Hypertension, Pulmonary/physiopathology
- Hypertrophy, Right Ventricular/drug therapy
- Hypertrophy, Right Ventricular/metabolism
- Hypertrophy, Right Ventricular/physiopathology
- Lung/drug effects
- Lung/metabolism
- Lung/physiopathology
- Male
- Methyl Ethers/administration & dosage
- Pulmonary Artery/drug effects
- Pulmonary Artery/metabolism
- Pulmonary Artery/physiopathology
- Rats
- Rats, Sprague-Dawley
- Sarcoplasmic Reticulum Calcium-Transporting ATPases/metabolism
- Sevoflurane
- Ventricular Dysfunction, Right/drug therapy
- Ventricular Dysfunction, Right/metabolism
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Function, Right/drug effects
- Ventricular Function, Right/physiology
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Affiliation(s)
- Xiaoqing Yin
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Lu Wang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Gang Qin
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Hui Luo
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiao Liu
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Fan Zhang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhi Ye
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Junjie Zhang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - E. Wang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
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22
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Fukumitsu M, Kawada T, Shimizu S, Turner MJ, Uemura K, Sugimachi M. Effects of Proximal Pulmonary Artery Occlusion on Pulsatile Right Ventricular Afterload in Rats. Circ J 2016; 80:2010-8. [DOI: 10.1253/circj.cj-16-0349] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Masafumi Fukumitsu
- Department of Artificial Organ Medicine, Faculty of Medicine, Osaka University Graduate School of Medicine
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center
| | - Shuji Shimizu
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center
| | - Michael J. Turner
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center
| | - Kazunori Uemura
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center
| | - Masaru Sugimachi
- Department of Artificial Organ Medicine, Faculty of Medicine, Osaka University Graduate School of Medicine
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center
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Axell RG, Hoole SP, Hampton-Till J, White PA. RV diastolic dysfunction: time to re-evaluate its importance in heart failure. Heart Fail Rev 2015; 20:363-73. [PMID: 25633340 DOI: 10.1007/s10741-015-9472-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Right ventricular (RV) diastolic dysfunction was first reported as an indicator for the assessment of ventricular dysfunction in heart failure a little over two decades ago. However, the underlying mechanisms and precise role of RV diastolic dysfunction in heart failure remain poorly described. Complexities in the structure and function of the RV make the detailed assessment of the contractile performance challenging when compared to its left ventricular (LV) counterpart. LV dysfunction is known to directly affect patient outcome in heart failure. As such, the focus has therefore been on LV function. Nevertheless, a strategy for the diagnosis and assessment of RV diastolic dysfunction has not been established. Here, we review the different causal mechanisms underlying RV diastolic dysfunction, summarising the current assessment techniques used in a clinical environment. Finally, we explore the role of load-independent indices of RV contractility, derived from the conductance technique, to fully interrogate the RV and expand our knowledge and understanding of RV diastolic dysfunction. Accurate assessment of RV contractility may yield further important prognostic information that will benefit patients with diastolic heart failure.
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Affiliation(s)
- Richard G Axell
- Medical Physics and Clinical Engineering, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK,
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24
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Guihaire J, Noly PE, Schrepfer S, Mercier O. Advancing knowledge of right ventricular pathophysiology in chronic pressure overload: Insights from experimental studies. Arch Cardiovasc Dis 2015; 108:519-29. [PMID: 26184869 DOI: 10.1016/j.acvd.2015.05.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 05/25/2015] [Accepted: 05/26/2015] [Indexed: 11/15/2022]
Abstract
The right ventricle (RV) has to face major changes in loading conditions due to cardiovascular diseases and pulmonary vascular disorders. Clinical experience supports evidence that the RV better compensates for volume than for pressure overload, and for chronic than for acute changes. For a long time, right ventricular (RV) pathophysiology has been restricted to patterns extrapolated from left heart studies. However, the two ventricles are anatomically, haemodynamically and functionally distinct. RV metabolic properties may also result in a different behaviour in response to pathological conditions compared with the left ventricle. In this review, current knowledge of RV pathophysiology is reported in the setting of chronic pressure overload, including recent experimental findings and emerging concepts. After a time-varying compensated period with preserved cardiac output despite overload conditions, RV failure finally occurs, leading to death. The underlying mechanisms involved in the transition from compensatory hypertrophy to maladaptive remodelling are not completely understood.
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Affiliation(s)
- Julien Guihaire
- Laboratory of Surgical Research, Marie-Lannelongue Hospital, Paris Sud University, 92350 Le Plessis Robinson, France; Thoracic and Cardiovascular Surgery, University Hospital of Rennes, 35033 Rennes, France.
| | - Pierre Emmanuel Noly
- Laboratory of Surgical Research, Marie-Lannelongue Hospital, Paris Sud University, 92350 Le Plessis Robinson, France
| | - Sonja Schrepfer
- Transplant and Stem Cell Immunobiology Laboratory (TSI Lab), University of Hamburg, Hamburg, Germany
| | - Olaf Mercier
- Laboratory of Surgical Research, Marie-Lannelongue Hospital, Paris Sud University, 92350 Le Plessis Robinson, France
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25
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HOLZEROVÁ K, HLAVÁČKOVÁ M, ŽURMANOVÁ J, BORCHERT G, NECKÁŘ J, KOLÁŘ F, NOVÁK F, NOVÁKOVÁ O. Involvement of PKCε in Cardioprotection Induced by Adaptation to Chronic Continuous Hypoxia. Physiol Res 2015; 64:191-201. [DOI: 10.33549/physiolres.932860] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Continuous normobaric hypoxia (CNH) renders the heart more tolerant to acute ischemia/reperfusion injury. Protein kinase C (PKC) is an important component of the protective signaling pathway, but the contribution of individual PKC isoforms under different hypoxic conditions is poorly understood. The aim of this study was to analyze the expression of PKCε after the adaptation to CNH and to clarify its role in increased cardiac ischemic tolerance with the use of PKCε inhibitory peptide KP-1633. Adult male Wistar rats were exposed to CNH (10 % O2, 3 weeks) or kept under normoxic conditions. The protein level of PKCε and its phosphorylated form was analyzed by Western blot in homogenate, cytosolic and particulate fractions; the expression of PKCε mRNA was measured by RT-PCR. The effect of KP-1633 on cell viability and lactate dehydrogenase (LDH) release was analyzed after 25-min metabolic inhibition followed by 30-min re-energization in freshly isolated left ventricular myocytes. Adaptation to CNH increased myocardial PKCε at protein and mRNA levels. The application of KP-1633 blunted the hypoxia-induced salutary effects on cell viability and LDH release, while control peptide KP-1723 had no effect. This study indicates that PKCε is involved in the cardioprotective mechanism induced by CNH.
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Affiliation(s)
| | - M. HLAVÁČKOVÁ
- Department of Developmental Cardiology, Institute of Physiology, Czech Academy of Sciences, Prague, Czech Republic
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26
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Gerges C, Skoro-Sajer N, Lang IM. Right ventricle in acute and chronic pulmonary embolism (2013 Grover Conference series). Pulm Circ 2015; 4:378-86. [PMID: 25621151 DOI: 10.1086/676748] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 02/27/2014] [Indexed: 02/02/2023] Open
Abstract
Venous thromboembolism (VTE) encompasses deep-vein thrombosis and pulmonary embolism (PE). It is the third-most-frequent cardiovascular disease, with an overall annual incidence of 1-2 per 1,000 population. Chronic thromboembolic pulmonary hypertension (CTEPH) is regarded as a late sequela of PE, with a reported incidence varying between 0.1% and 9.1% of those surviving acute VTE. Right ventricular (RV) function is dependent on afterload. The most precise technique to describe RV function is invasive assessment of the RV-to-pulmonary vascular coupling. However, assessments of RV afterload (i.e., steady and pulsatile flow components and their product, the RC-time) may be useful hemodynamic surrogates of coupling. RV load is different in acute and chronic PE. In acute PE, more than 60% occlusion of the cross-sectional area of the pulmonary artery within a short period of time leads to abrupt hemodynamic collapse. If the time of occlusion is limited to ∼15 seconds, significant decreases in fractional area change, tricuspid annulus systolic excursion, and RV free-wall deformation (strain) occur, with the latter showing significant postsystolic shortening. These changes have similarities to ischemic stunning, and they recover within minutes. In CTEPH, studies of pulmonary vascular resistance (PVR) and pulmonary arterial compliance demonstrated low RC-times that were further lowered after pulmonary endarterectomy (PEA). Immediate postoperative PVR was the only predictor of long-term survival/freedom from lung transplantation, suggesting that the effect of PEA on opening vascular territories to flow outweighs its effect on proximal stiffness. This review summarizes the current knowledge on vascular and intrinsic RV adaptation to VTE, including CTEPH, and the role of imaging.
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Affiliation(s)
- Christian Gerges
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Nika Skoro-Sajer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
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27
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Naeije R, Brimioulle S, Dewachter L. Biomechanics of the right ventricle in health and disease (2013 Grover Conference series). Pulm Circ 2015; 4:395-406. [PMID: 25621153 DOI: 10.1086/677354] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 01/22/2014] [Indexed: 02/02/2023] Open
Abstract
Right ventricular (RV) function is a major determinant of the symptomatology and outcome in pulmonary hypertension. The normal RV is a thin-walled flow generator able to accommodate large changes in venous return but unable to maintain flow output in the presence of a brisk increase in pulmonary artery pressure. The RV chronically exposed to pulmonary hypertension undergoes hypertrophic changes and an increase in contractility, allowing for preserved flow output in response to peripheral demand. Failure of systolic function adaptation (homeometric adaptation, described by Anrep's law of the heart) results in increased dimensions (heterometric adaptation; Starling's law of the heart), with a negative effect on diastolic ventricular interactions, limitation of exercise capacity, and vascular congestion. Ventricular function is described by pressure-volume relationships. The gold standard of systolic function is maximum elastance (E max), or the maximal value of the ratio of pressure to volume. This value is not immediately sensitive to changes in loading conditions. The gold standard of afterload is arterial elastance (E a), defined by the ratio of pressure at E max to stroke volume. The optimal coupling of ventricular function to the arterial circulation occurs at an E max/E a ratio between 1.5 and 2. Patients with severe pulmonary hypertension present with an increased E max, a trend toward decreased E max/E a, and increased RV dimensions, along with progression of the pulmonary vascular disease, systemic factors, and left ventricular function. The molecular mechanisms of RV systolic failure are currently being investigated. It is important to refer biological findings to sound measurements of function. Surrogates for E max and E a are being developed through bedside imaging techniques.
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Affiliation(s)
- Robert Naeije
- Department of Physiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium
| | - Serge Brimioulle
- Department of Physiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium
| | - Laurence Dewachter
- Department of Physiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium
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28
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29
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Evaluation of Right Ventricular Myocardial Function in Healthy Horses With Recurrent Airway Obstruction Using Tissue Doppler Imaging. J Equine Vet Sci 2014. [DOI: 10.1016/j.jevs.2014.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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30
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Leite-Moreira AF, Lourenço AP, Balligand JL, Bauersachs J, Clerk A, De Windt LJ, Heymans S, Hilfiker-Kleiner D, Hirsch E, Iaccarino G, Kaminski KA, Knöll R, Mayr M, Tarone G, Thum T, Tocchetti CG. ESC Working Group on Myocardial Function Position Paper: how to study the right ventricle in experimental models. Eur J Heart Fail 2014; 16:509-18. [PMID: 24574252 DOI: 10.1002/ejhf.66] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 11/25/2013] [Accepted: 01/17/2014] [Indexed: 11/09/2022] Open
Abstract
The right ventricle has become an increasing focus in cardiovascular research. In this position paper, we give a brief overview of the specific pathophysiological features of the right ventricle, with particular emphasis on functional and molecular modifications as well as therapeutic strategies in chronic overload, highlighting the differences from the left ventricle. Importantly, we put together recommendations on promising topics of research in the field, experimental study design, and functional evaluation of the right ventricle in experimental models, from non-invasive methodologies to haemodynamic evaluation and ex vivo set-ups.
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Affiliation(s)
- Adelino F Leite-Moreira
- Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Al. Prof. Hernani Monteiro, 4200 319, Porto, Portugal
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31
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McCabe C, White PA, Hoole SP, Axell RG, Priest AN, Gopalan D, Taboada D, MacKenzie Ross R, Morrell NW, Shapiro LM, Pepke-Zaba J. Right ventricular dysfunction in chronic thromboembolic obstruction of the pulmonary artery: a pressure-volume study using the conductance catheter. J Appl Physiol (1985) 2013; 116:355-63. [PMID: 24356516 DOI: 10.1152/japplphysiol.01123.2013] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pressure-volume loops describe dynamic ventricular performance, relevant to patients with and at risk of pulmonary hypertension. We used conductance catheter-derived pressure-volume loops to measure right ventricular (RV) mechanics in patients with chronic thromboembolic pulmonary arterial obstruction at different stages of pathological adaptation. Resting conductance catheterization was performed in 24 patients: 10 with chronic thromboembolic pulmonary hypertension (CTEPH), 7 with chronic thromboembolic disease without pulmonary hypertension (CTED), and 7 controls. To assess the validity of conductance measurements, RV volumes were compared in a subset of 8 patients with contemporaneous cardiac magnetic resonance (CMR). Control, CTED, and CTEPH groups showed different pressure-volume loop morphology, most notable during systolic ejection. Prolonged diastolic relaxation was seen in patients with CTED and CTEPH [tau = 56.2 ± 6.7 (controls) vs. 69.7 ± 10.0 (CTED) vs. 67.9 ± 6.2 ms (CTEPH), P = 0.02]. Control and CTED groups had lower afterload (Ea) and contractility (Ees) compared with the CTEPH group (Ea = 0.30 ± 0.10 vs. 0.52 ± 0.24 vs. 1.92 ± 0.70 mmHg/ml, respectively, P < 0.001) (Ees = 0.44 ± 0.20 vs. 0.59 ± 0.15 vs. 1.13 ± 0.43 mmHg/ml, P < 0.01) with more efficient ventriculoarterial coupling (Ees/Ea = 1.46 ± 0.30 vs. 1.27 ± 0.36 vs. 0.60 ± 0.18, respectively, P < 0.001). Stroke volume assessed by CMR and conductance showed closest agreement (mean bias +9 ml, 95% CI -1 to +19 ml) compared with end-diastolic volume (+48 ml, -16 to 111 ml) and end-systolic volume (+37 ml, -21 to 94 ml). RV conductance catheterization detects novel alteration in pressure-volume loop morphology and delayed RV relaxation in CTED, which distinguish this group from controls. The observed agreement in stroke volume assessed by CMR and conductance suggests RV mechanics are usefully measured by conductance catheter in chronic thromboembolic obstruction.
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Affiliation(s)
- Colm McCabe
- Pulmonary Vascular Disease Unit, Papworth Hospital, Cambridge, United Kingdom
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32
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Tewari SG, Bugenhagen SM, Wang Z, Schreier DA, Carlson BE, Chesler NC, Beard DA. Analysis of cardiovascular dynamics in pulmonary hypertensive C57BL6/J mice. Front Physiol 2013; 4:355. [PMID: 24376421 PMCID: PMC3858724 DOI: 10.3389/fphys.2013.00355] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 11/20/2013] [Indexed: 12/03/2022] Open
Abstract
A computer model was used to analyze data on cardiac and vascular mechanics from C57BL6/J mice exposed to 0 (n = 4), 14 (n = 6), 21 (n = 8) and 28 (n = 7) days of chronic hypoxia and treatment with the VEGF receptor inhibitor SUGEN (HySu) to induce pulmonary hypertension. Data on right ventricular pressure and volume, and systemic arterial pressure obtained before, during, and after inferior vena cava occlusion were analyzed using a mathematical model of realistic ventricular mechanics coupled with a simple model of the pulmonary and systemic vascular systems. The model invokes a total of 26 adjustable parameters, which were estimated based on least-squares fitting of the data. Of the 26 adjustable parameters, 14 were set to globally constant values for the entire data set. It was necessary to adjust the remaining 12 parameters to match data from all experimental groups. Of these 12 individually adjusted parameters, three parameters representing pulmonary vascular resistance, pulmonary arterial elastance, and pulmonary arterial narrowing were found to significantly change in HySu-induced remodeling. Model analysis shows a monotonic change in these parameters as disease progressed, with approximately 130% increase in pulmonary resistance, 70% decrease in unstressed pulmonary arterial volume, and 110% increase in pulmonary arterial elastance in the 28-day group compared to the control group. These changes are consistent with prior experimental measurements. Furthermore, the 28-day data could be explained only after increasing the passive elastance of the right free wall compared to the value used for the other data sets, which is likely a consequence of the increased RV collagen accumulation found experimentally. These findings may indicate a compensatory remodeling followed by pathological remodeling of the right ventricle in HySu-induced pulmonary hypertension.
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Affiliation(s)
- Shivendra G Tewari
- Biotechnology and Bioengineering Center, Medical College of Wisconsin Milwaukee, WI, USA
| | - Scott M Bugenhagen
- Biotechnology and Bioengineering Center, Medical College of Wisconsin Milwaukee, WI, USA ; Department of Physiology, Medical College of Wisconsin Milwaukee, WI, USA
| | - Zhijie Wang
- Department of Biomedical Engineering, University of Wisconsin-Madison Madison, WI, USA
| | - David A Schreier
- Department of Biomedical Engineering, University of Wisconsin-Madison Madison, WI, USA
| | - Brian E Carlson
- Biotechnology and Bioengineering Center, Medical College of Wisconsin Milwaukee, WI, USA ; Department of Physiology, Medical College of Wisconsin Milwaukee, WI, USA
| | - Naomi C Chesler
- Department of Biomedical Engineering, University of Wisconsin-Madison Madison, WI, USA
| | - Daniel A Beard
- Biotechnology and Bioengineering Center, Medical College of Wisconsin Milwaukee, WI, USA ; Department of Physiology, Medical College of Wisconsin Milwaukee, WI, USA
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33
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Trepte CJ, Haas SA, Nitzschke R, Salzwedel C, Goetz AE, Reuter DA. Prediction of Volume-Responsiveness During One-Lung Ventilation: A Comparison of Static, Volumetric, and Dynamic Parameters of Cardiac Preload. J Cardiothorac Vasc Anesth 2013; 27:1094-100. [DOI: 10.1053/j.jvca.2013.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Indexed: 11/11/2022]
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34
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Guihaire J, Haddad F, Boulate D, Decante B, Denault AY, Wu J, Herve P, Humbert M, Dartevelle P, Verhoye JP, Mercier O, Fadel E. Non-invasive indices of right ventricular function are markers of ventricular-arterial coupling rather than ventricular contractility: insights from a porcine model of chronic pressure overload. Eur Heart J Cardiovasc Imaging 2013; 14:1140-9. [DOI: 10.1093/ehjci/jet092] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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35
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Wang Z, Chesler NC. Pulmonary vascular mechanics: important contributors to the increased right ventricular afterload of pulmonary hypertension. Exp Physiol 2013; 98:1267-73. [PMID: 23666792 DOI: 10.1113/expphysiol.2012.069096] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Chronic hypoxia causes pulmonary vasoconstriction and vascular remodelling, which lead to hypoxic pulmonary hypertension (HPH). Hypoxic pulmonary hypertension is associated with living at high altitudes and is a complication of many lung diseases, including chronic obstructive pulmonary disease, cystic fibrosis and obstructive sleep apnoea. Pulmonary vascular changes that occur with HPH include stiffening and narrowing of the pulmonary arteries that appear to involve all vascular cell types and sublayers of the arterial wall. Right ventricular (RV) changes that occur with HPH include RV hypertrophy and RV fibrosis, often with preserved systolic and diastolic function and ventricular-vascular coupling efficiency. Both vascular stiffening and vascular narrowing are important contributors to RV afterload via increases in oscillatory and steady ventricular work, respectively. The increased blood viscosity that occurs in HPH can be dramatic and is another important contributor to RV afterload. However, the viscosity, vascular mechanics and ventricular changes that occur with HPH are all reversible. Furthermore, even with continued hypoxia the vascular remodelling does not progress to the obliterative, plexiform lesions that are seen clinically in severe pulmonary hypertension. In animal models, the RV changes appear adaptive, not maladaptive. In summary, HPH-induced vascular mechanical changes affect ventricular function, but both are adaptive and reversible, which differentiates HPH from severe pulmonary hypertension. The mechanisms of adaptation and reversibility may provide useful insight into therapeutic targets for the clinical disease state.
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Affiliation(s)
- Zhijie Wang
- Department of Biomedical Engineering, University of Wisconsin–Madison, Madison, WI 53706, USA
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Pagnamenta A, Vanderpool R, Brimioulle S, Naeije R. Proximal pulmonary arterial obstruction decreases the time constant of the pulmonary circulation and increases right ventricular afterload. J Appl Physiol (1985) 2013; 114:1586-92. [PMID: 23539317 DOI: 10.1152/japplphysiol.00033.2013] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The time constant of the pulmonary circulation, or product of pulmonary vascular resistance (PVR) and compliance (Ca), called the RC-time, has been reported to remain constant over a wide range of pressures, etiologies of pulmonary hypertension, and treatments. We wondered if increased wave reflection on proximal pulmonary vascular obstruction, like in operable chronic thromboembolic pulmonary hypertension, might also decrease the RC-time and thereby increase pulse pressure and right ventricular afterload. Pulmonary hypertension of variable severity was induced either by proximal obstruction (pulmonary arterial ensnarement) or distal obstruction (microembolism) eight anesthetized dogs. Pulmonary arterial pressures (Ppa) were measured with high-fidelity micromanometer-tipped catheters, and pulmonary flow with transonic technology. Pulmonary ensnarement increased mean Ppa, PVR, and characteristic impedance, decreased Ca and the RC-time (from 0.46 ± 0.07 to 0.30 ± 0.03 s), and increased the oscillatory component of hydraulic load (Wosc/Wtot) from 25 ± 2 to 29 ± 2%. Pulmonary microembolism increased mean Ppa and PVR, with no significant change in Ca and characteristic impedance, increased RC-time from 0.53 ± 0.09 to 0.74 ± 0.05 s, and decreased Wosc/Wtot from 26 ± 2 to 13 ± 2%. Pulse pressure increased more after pulmonary ensnarement than after microembolism. Concomitant measurements with fluid-filled catheters showed the same functional differences between the two types of pulmonary hypertension, with, however, an underestimation of Wosc. We conclude that pulmonary hypertension caused by proximal vs. distal obstruction is associated with a decreased RC-time and increased pulsatile component of right ventricular hydraulic load.
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Affiliation(s)
- Alberto Pagnamenta
- Department of Physiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium
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Methods for measuring right ventricular function and hemodynamic coupling with the pulmonary vasculature. Ann Biomed Eng 2013; 41:1384-98. [PMID: 23423705 DOI: 10.1007/s10439-013-0752-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 01/21/2013] [Indexed: 12/11/2022]
Abstract
The right ventricle (RV) is a pulsatile pump, the efficiency of which depends on proper hemodynamic coupling with the compliant pulmonary circulation. The RV and pulmonary circulation exhibit structural and functional differences with the more extensively investigated left ventricle (LV) and systemic circulation. In light of these differences, metrics of LV function and efficiency of coupling to the systemic circulation cannot be used without modification to characterize RV function and efficiency of coupling to the pulmonary circulation. In this article, we review RV physiology and mechanics, established and novel methods for measuring RV function and hemodynamic coupling, and findings from application of these methods to RV function and coupling changes with pulmonary hypertension. We especially focus on non-invasive measurements, as these may represent the future for clinical monitoring of disease progression and the effect of drug therapies.
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Abstract
Our ability to evaluate the right ventricle (RV) in pulmonary hypertension has traditionally been quite limited: the RV's complex anatomy is not adequately represented by 2-dimensional imaging, and our understanding of what is an adaptive and maladaptive RV response is incomplete. However, measures of RV function appear to be a strong predictor of survival in pulmonary hypertension. This is, therefore, a promising area for future study. To more fully understand the challenges and opportunities in this area, this article provides a review of RV embryology and anatomy, current assessment of the RV function, animal models of RV function, RV-pulmonary artery coupling, and how translating lessons from studies of the left ventricle may increase our knowledge of the RV.
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Bellofiore A, Roldán-Alzate A, Besse M, Kellihan HB, Consigny DW, Francois CJ, Chesler NC. Impact of acute pulmonary embolization on arterial stiffening and right ventricular function in dogs. Ann Biomed Eng 2012; 41:195-204. [PMID: 22864865 DOI: 10.1007/s10439-012-0635-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 07/21/2012] [Indexed: 01/23/2023]
Abstract
Pulmonary hypertension (PH) can impact right ventricular (RV) function and alter pulmonary artery (PA) stiffness. The response of the RV to an acute increase in pulmonary pressure is unclear. In addition, the relation between total pulmonary arterial compliance and local PA stiffness has not been investigated. We used a combination of right heart catheterization (RHC) and magnetic resonance imaging (MRI) to assess PA stiffening and RV function in dogs before and after acute embolization. We hypothesized that in moderate, acute PH the RV is able to compensate for increased afterload, maintaining adequate coupling. Also, we hypothesized that in the absence of PA remodeling the relative area change in the proximal PA (RAC, a noninvasive index of local area strain) correlates with the total arterial compliance (stroke volume-to-pulse pressure ratio). Our results indicate that, after embolization, RV function is able to accommodate the demand for increased stroke work without uncoupling, albeit at the expense of a reduction of efficiency. In this acute model, RAC showed excellent correlation with total arterial compliance. We used this correlation to assess PA pulse pressure (PP) from noninvasive MRI measurements of stroke volume and RAC. We demonstrated that in acute pulmonary embolism MRI estimates of PP are remarkably close to measurements from RHC. These results, if confirmed in chronic PH and clinically, suggest that monitoring of PH progression by noninvasive methods may be possible.
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Affiliation(s)
- Alessandro Bellofiore
- Department of Biomedical Engineering, University of Wisconsin-Madison, 1550 Engineering Drive, Madison, WI 53706-1609, USA
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Conséquences hémodynamiques de l’embolie pulmonaire. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0449-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
The pulmonary circulation is a high-flow and low-pressure circuit, with an average resistance of 1 mmHg/min/L in young adults, increasing to 2.5 mmHg/min/L over four to six decades of life. Pulmonary vascular mechanics at exercise are best described by distensible models. Exercise does not appear to affect the time constant of the pulmonary circulation or the longitudinal distribution of resistances. Very high flows are associated with high capillary pressures, up to a 20 to 25 mmHg threshold associated with interstitial lung edema and altered ventilation/perfusion relationships. Pulmonary artery pressures of 40 to 50 mmHg, which can be achieved at maximal exercise, may correspond to the extreme of tolerable right ventricular afterload. Distension of capillaries that decrease resistance may be of adaptative value during exercise, but this is limited by hypoxemia from altered diffusion/perfusion relationships. Exercise in hypoxia is associated with higher pulmonary vascular pressures and lower maximal cardiac output, with increased likelihood of right ventricular function limitation and altered gas exchange by interstitial lung edema. Pharmacological interventions aimed at the reduction of pulmonary vascular tone have little effect on pulmonary vascular pressure-flow relationships in normoxia, but may decrease resistance in hypoxia, unloading the right ventricle and thereby improving exercise capacity. Exercise in patients with pulmonary hypertension is associated with sharp increases in pulmonary artery pressure and a right ventricular limitation of aerobic capacity. Exercise stress testing to determine multipoint pulmonary vascular pressures-flow relationships may uncover early stage pulmonary vascular disease.
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Affiliation(s)
- R NAEIJE
- Department of Physiology, Erasme Campus of the Free University of Brussels, CP 604, 808, Lennik road, B-1070 Brussels, BELGIUM, Tel +32 2 5553322, Fax +32 2 5554124
| | - N CHESLER
- University of Wisconsin at Madison, 2146 Engineering Centers Building, 1550 Engineering drive, Madison, Wisconsin 53706-1609, USA, Tel +1 608 265 8920, Fax +1 608 265 9239
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Abstract
It has been known for more than 60 years, and suspected for over 100, that alveolar hypoxia causes pulmonary vasoconstriction by means of mechanisms local to the lung. For the last 20 years, it has been clear that the essential sensor, transduction, and effector mechanisms responsible for hypoxic pulmonary vasoconstriction (HPV) reside in the pulmonary arterial smooth muscle cell. The main focus of this review is the cellular and molecular work performed to clarify these intrinsic mechanisms and to determine how they are facilitated and inhibited by the extrinsic influences of other cells. Because the interaction of intrinsic and extrinsic mechanisms is likely to shape expression of HPV in vivo, we relate results obtained in cells to HPV in more intact preparations, such as intact and isolated lungs and isolated pulmonary vessels. Finally, we evaluate evidence regarding the contribution of HPV to the physiological and pathophysiological processes involved in the transition from fetal to neonatal life, pulmonary gas exchange, high-altitude pulmonary edema, and pulmonary hypertension. Although understanding of HPV has advanced significantly, major areas of ignorance and uncertainty await resolution.
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Affiliation(s)
- J T Sylvester
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, The Johns Hopkins University School ofMedicine, Baltimore, Maryland, USA.
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Wang Z, Chesler NC. Pulmonary vascular wall stiffness: An important contributor to the increased right ventricular afterload with pulmonary hypertension. Pulm Circ 2011; 1:212-23. [PMID: 22034607 PMCID: PMC3198648 DOI: 10.4103/2045-8932.83453] [Citation(s) in RCA: 147] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Pulmonary hypertension (PH) is associated with structural and mechanical changes in the pulmonary vascular bed that increase right ventricular (RV) afterload. These changes, characterized by narrowing and stiffening, occur in both proximal and distal pulmonary arteries (PAs). An important consequence of arterial narrowing is increased pulmonary vascular resistance (PVR). Arterial stiffening, which can occur in both the proximal and distal pulmonary arteries, is an important index of disease progression and is a significant contributor to increased RV afterload in PH. In particular, arterial narrowing and stiffening increase the RV afterload by increasing steady and oscillatory RV work, respectively. Here we review the current state of knowledge of the causes and consequences of pulmonary arterial stiffening in PH and its impact on RV function. We review direct and indirect techniques for measuring proximal and distal pulmonary arterial stiffness, measures of arterial stiffness including elastic modulus, incremental elastic modulus, stiffness coefficient β and others, the changes in cellular function and the extracellular matrix proteins that contribute to pulmonary arterial stiffening, the consequences of PA stiffening for RV function and the clinical implications of pulmonary vascular stiffening for PH progression. Future investigation of the relationship between PA stiffening and RV dysfunction may facilitate new therapies aimed at improving RV function and thus ultimately reducing mortality in PH.
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Affiliation(s)
- Zhijie Wang
- Department of Biomedical Engineering, University of Wisconsin-Madison, Wisconsin, USA
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Revie JA, Stevenson DJ, Chase JG, Hann CE, Lambermont BC, Ghuysen A, Kolh P, Morimont P, Shaw GM, Desaive T. Clinical detection and monitoring of acute pulmonary embolism: proof of concept of a computer-based method. Ann Intensive Care 2011; 1:33. [PMID: 21906388 PMCID: PMC3224493 DOI: 10.1186/2110-5820-1-33] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 08/11/2011] [Indexed: 11/17/2022] Open
Abstract
Background The diagnostic ability of computer-based methods for cardiovascular system (CVS) monitoring offers significant clinical potential. This research tests the clinical applicability of a newly improved computer-based method for the proof of concept case of tracking changes in important hemodynamic indices due to the influence acute pulmonary embolism (APE). Methods Hemodynamic measurements from a porcine model of APE were used to validate the method. Of these measurements, only those that are clinically available or inferable were used in to identify pig-specific computer models of the CVS, including the aortic and pulmonary artery pressure, stroke volume, heart rate, global end diastolic volume, and mitral and tricuspid valve closure times. Changes in the computer-derived parameters were analyzed and compared with experimental metrics and clinical indices to assess the clinical applicability of the technique and its ability to track the disease state. Results The subject-specific computer models accurately captured the increase in pulmonary resistance (Rpul), the main cardiovascular consequence of APE, in all five pigs trials, which related well (R2 = 0.81) with the experimentally derived pulmonary vascular resistance. An increase in right ventricular contractility was identified, as expected, consistent with known reflex responses to APE. Furthermore, the modeled right ventricular expansion index (the ratio of right to left ventricular end diastolic volumes) closely followed the trends seen in the measured data (R2 = 0.92) used for validation, with sharp increases seen in the metric for the two pigs in a near-death state. These results show that the pig-specific models are capable of tracking disease-dependent changes in pulmonary resistance (afterload), right ventricular contractility (inotropy), and ventricular loading (preload) during induced APE. Continuous, accurate estimation of these fundamental metrics of cardiovascular status can help to assist clinicians with diagnosis, monitoring, and therapy-based decisions in an intensive care environment. Furthermore, because the method only uses measurements already available in the ICU, it can be implemented with no added risk to the patient and little extra cost. Conclusions This computer-based monitoring method shows potential for real-time, continuous diagnosis and monitoring of acute CVS dysfunction in critically ill patients.
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Affiliation(s)
- James A Revie
- Cardiovascular Research Center, University of Liege, Belgium.
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Kerbaul F, By Y, Gariboldi V, Mekkaoui C, Fesler P, Collart F, Brimioulle S, Jammes Y, Ruf J, Guieu R. Acute pulmonary embolism decreases adenosine plasma levels in anesthetized pigs. ISRN CARDIOLOGY 2011; 2011:750301. [PMID: 22347654 PMCID: PMC3262497 DOI: 10.5402/2011/750301] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 03/30/2011] [Indexed: 11/26/2022]
Abstract
Adenosine plays a role in pulmonary arterial (PA) resistance due to its vasodilator properties. However, the behavior of adenosine plasma levels (APLs) during pulmonary embolism remains unknown. We investigated the effects of gradual pulmonary embolism on right ventricular (RV) contractility and PA coupling and on APLs in an piglet experimental model of RV failure. PA distal resistance by pressure-flow relationships and pulmonary vascular impedance were measured. RV contractility was determined by the end-systolic pressure-volume relationship (Ees), PA effective elastance by the end-diastolic to end-systolic relationship (Ea), and RV-PA coupling efficiency by the Ees/Ea ratio. APLs were measured before and during gradual pulmonary embolization. PA embolism increased PA resistance and elastance, increased Ea from 1.08 ± 0.15
to 5.62 ± 0.32 mmHg/mL, decreased Ees from 1.82 ± 0.10 to 1.20 ± 0.23 mmHg/mL, and decreased Ees/Ea from 1.69 ± 0.15 to 0.21 ± 0.07. APLs decreased from 2.7 ± 0.26 to 1.3 ± 0.12 μM in the systemic bed and from 4.03 ± 0.63 to 2.51 ± 0.58 μM in the pulmonary bed during embolism procedure. Pulmonary embolism worsens PA hemodynamics and RV-PA coupling. APLs were reduced, both in the systemic and in the pulmonary bed, leading then to pulmonary vasoconstriction.
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Affiliation(s)
- François Kerbaul
- Laboratory of Hemodynamic and Cardiovascular Mechanisms, and Departments of Intensive Care, AP-HM, 13385 Marseille Cedex 05, France
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Tabima DM, Hacker TA, Chesler NC. Measuring right ventricular function in the normal and hypertensive mouse hearts using admittance-derived pressure-volume loops. Am J Physiol Heart Circ Physiol 2010; 299:H2069-75. [PMID: 20935149 DOI: 10.1152/ajpheart.00805.2010] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Mice are a widely used animal model for investigating cardiovascular disease. Novel technologies have been used to quantify left ventricular function in this species, but techniques appropriate for determining right ventricular (RV) function are less well demonstrated. Detecting RV dysfunction is critical to assessing the progression of pulmonary vascular diseases such as pulmonary hypertension. We used an admittance catheter to measure pressure-volume loops in anesthetized, open-chested mice before and during vena cava occlusion. Mice exposed to chronic hypoxia for 10 days, which causes hypoxia-induced pulmonary hypertension (HPH), were compared with control (CTL) mice. HPH resulted in a 27.9% increase in RV mass (P < 0.005), a 67.5% increase in RV systolic pressure (P < 0.005), and a 61.2% decrease in cardiac output (P < 0.05). Preload recruitable stroke work (PRSW) and slope of the maximum derivative of pressure (dP/dt(max))-end-diastolic volume (EDV) relationship increased with HPH (P < 0.05). Although HPH increased effective arterial elastance (E(a)) over fivefold (from 2.7 ± 1.2 to 16.4 ± 2.5 mmHg/μl), only a mild increase in the ventricular end-systolic elastance (E(es)) was observed. As a result, a dramatic decrease in the efficiency of ventricular-vascular coupling occurred (E(es)/E(a) decreased from 0.71 ± 0.27 to 0.35 ± 0.17; P < 0.005). Changes in cardiac reserve were evaluated by dobutamine infusion. In CTL mice, dobutamine significantly enhanced E(es) and dP/dt(max)-EDV but also increased E(a), causing a decrease in E(es)/E(a). In HPH mice, slight but nonsignificant decreases in E(es), PRSW, dP/dt(max)-EDV, and E(a) were observed. Thus 10 days of HPH resulted in RV hypertrophy, ventricular-vascular decoupling, and a mild decrease in RV contractile reserve. This study demonstrates the feasibility of obtaining RV pressure-volume measurements in mice. These measurements provide insight into ventricular-vascular interactions healthy and diseased states.
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Affiliation(s)
- Diana M Tabima
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin 53706-1609, USA
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Toshner MR, Gopalan D, Suntharalingam J, Treacy C, Soon E, Sheares KK, Morrell NW, Screaton N, Pepke-Zaba J. Pulmonary arterial size and response to sildenafil in chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2010; 29:610-5. [PMID: 20227301 PMCID: PMC2954311 DOI: 10.1016/j.healun.2009.12.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Revised: 12/07/2009] [Accepted: 12/15/2009] [Indexed: 11/25/2022] Open
Abstract
Background Relative area change (RAC) of the proximal pulmonary artery is a measurement of pulmonary artery distensibility and has been shown to correlate with vasoreactivity studies in patients with idiopathic pulmonary arterial hypertension. We have previously noted a relationship between invasive hemodynamic vasoreactivity testing and long-term response to sildenafil in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). We therefore set out to determine whether RAC can provide useful correlatory non-invasive data. Methods Patients recruited to a randomized, controlled trial (RCT) of sildenafil at 40 mg 3 times daily underwent additional magnetic resonance imaging (MRI) at the baseline of the trial. Eighteen patients had an MRI that led to a diagnosis of inoperable distal CTEPH or significant residual CTEPH post-operatively. The primary end-point was improvement in 6-minute walk test (6MWT) with secondary end-points of right heart catheterization–based hemodynamics, N-terminal pro–brain natriuretic peptide (NT pro-BNP) and functional class. RAC assessed by MRI was correlated with trial end-points. Results Fourteen subjects with baseline MRI completed the protocol. RAC was the only baseline variable that correlated at 1 year to the primary end-point of improvement in 6MWT (r = 0.7, p = 0.006), and also to a change in NT pro-BNP (r = 0.59, p = 0.03). Using a cut-off of RAC over 20% there was an 87.5% sensitivity (95% confidence interval [CI]: 45% to 100%) and a 66.7% specificity (95% CI: 22% to 96%) for an improvement in 6MWT of >40 meters. Conclusions RAC correlates with functional response to sildenafil, as measured by the 6MWT, and improved heart function, as measured by NT pro-BNP. RAC shows potential in understanding and possibly predicting treatment response.
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Affiliation(s)
- Mark R Toshner
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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Plehn G, Vormbrock J, Perings S, Plehn A, Meissner A, Butz T, Trappe HJ. Comparison of right ventricular functional response to exercise in hypertrophic versus idiopathic dilated cardiomyopathy. Am J Cardiol 2010; 105:116-21. [PMID: 20102902 DOI: 10.1016/j.amjcard.2009.08.662] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Revised: 08/07/2009] [Accepted: 08/07/2009] [Indexed: 11/24/2022]
Abstract
Although the biventricular nature of the disease has been confirmed by morphologic studies, information on right ventricular (RV) function in hypertrophic cardiomyopathy (HC) is lacking. The aim of the study was to hemodynamically characterize RV performance in HC versus idiopathic dilated cardiomyopathy (IDC) during exercise. The hemodynamic data of 63 patients with HC who underwent hemodynamic exercise testing with thermodilution-derived assessment of RV ejection fraction were analyzed. The results were compared to a healthy control group (n = 20) and to patients with IDC (n = 86). The baseline RV ejection fraction was increased in the patients with HC compared to those with IDC (39 +/- 10% vs 33 +/- 12%; p = 0.002), but did not differ compared to controls (42 +/- 7% vs 39 +/- 10%; p = NS). An increase in end-diastolic volume from rest to exercise contributed to stroke volume augmentation in those with HC (121 +/- 38 vs 136 +/- 55 ml/m(2); p = 0.01) and control subjects (116 +/- 34 vs 138 +/- 31 ml/m(2); p = 0.002) but not in those with IDC (117 +/- 47 vs 120 +/- 52 ml/m(2); p = NS). At peak exercise the RV ejection fraction in those with HC was reduced compared to that in the controls (45 +/- 11% vs 59% +/- 9%; p <0.001), but it was increased compared to that in those with IDC (45 +/- 11% vs 35% +/- 11%; p <0.001). In conclusion, the extent of the pulmonary pressure increase was more pronounced in those with HC than in those with IDC, but the degree of functional impairment of the right ventricle was less severe, probably owing to its ability to recruit preload and contractile reserve with exercise.
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