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Kremer N, Glocker F, Schäfer S, Rako Z, Yogeswaran A, Seeger W, Hopf H, Tello K. Precision cardiac monitoring: algorithmic real-time assessment of right ventricular function in pulmonary hypertension. ESC Heart Fail 2024; 11:2469-2472. [PMID: 38689380 PMCID: PMC11287341 DOI: 10.1002/ehf2.14833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 03/13/2024] [Accepted: 04/10/2024] [Indexed: 05/02/2024] Open
Affiliation(s)
- Nils Kremer
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center, German Center for Lung ResearchGiessenGermany
| | | | - Simon Schäfer
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center, German Center for Lung ResearchGiessenGermany
| | - Zvonimir Rako
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center, German Center for Lung ResearchGiessenGermany
| | - Athiththan Yogeswaran
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center, German Center for Lung ResearchGiessenGermany
| | - Werner Seeger
- Department of Internal MedicineUniversities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), German Center for Lung Research (DZL)GiessenGermany
| | | | - Khodr Tello
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center, German Center for Lung ResearchGiessenGermany
- Krankenhaus NordwestFrankfurt am MainFrankfurtGermany
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2
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Dammassa V, Colombo CNJ, Erba M, Ciarrocchi F, Pagani M, Price S, Mojoli F, Tavazzi G. Echocardiographic assessment of right ventricular performance in COVID-19 related acute respiratory distress syndrome: the importance of systo-diastolic interaction. Ultrasound J 2024; 16:26. [PMID: 38713303 PMCID: PMC11076422 DOI: 10.1186/s13089-024-00366-5] [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: 08/17/2023] [Accepted: 02/20/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND The cardiac manifestations of COVID-19 have been described in patients with acute respiratory distress syndrome (ARDS) admitted to intensive care unit (ICU). The presence and impact of right ventricular (RV) diastolic function and performance has not been studied in this population yet. We describe the prevalence of RV diastolic dysfunction, assessed by the pulmonary valve pre-ejection A wave (PV A wave), and the RV systo-diastolic interaction, using the RV total isovolumic time (t-IVT), in COVID-19 ARDS. RESULTS Prospective observational study enrolling patients with moderate to severe COVID-19 ARDS admitted to ICU who underwent a transthoracic echocardiogram within 24 h of ICU admission and at least a second one during the ICU stay. Respiratory, hemodynamic and biochemistry parameters were collected. 163 patients (age 61.0 ± 9.3 years, 72% males) were enrolled. 36 patients (22.1%) had RV dysfunction, 45 (27.1%) LV systolic dysfunction. 73 patients (44.7%) had PV A wave. The RV t-IVT correlated with TAPSE at ICU admission (p < 0.002; r - 0.61), presence of PV A wave (p < 0.001; r 0.78), peak inspiratory pressure (PIP) (p < 0.001; r 0.42), PEEP (p < 0.001; r 0.68), dynamic driving pressure (DDP) (p < 0.001; r 0.58), and PaO2/FiO2 ratio (p < 0.01; r - 0.35). The presence of PV A wave was associated with higher PIP (p < 0.001; r 0.45), higher PEEP (p < 0.001; r 0.56), higher DDP (p < 0.01, r 0.51), and lower PaO2/FiO2 ratio (p < 0.001; r - 0.49). CONCLUSIONS RV t-IVT and the presence of PV A wave are non-invasive means to describe a significant RV diastolic dysfunction and may be consider descriptive signs of RV performance in COVID-19 ARDS.
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Affiliation(s)
- Valentino Dammassa
- Department of Experimental Medicine, University of Pavia, Pavia, Italy
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Costanza Natalia Julia Colombo
- Department of Experimental Medicine, University of Pavia, Pavia, Italy
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Massimo Erba
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabio Ciarrocchi
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Michele Pagani
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Francesco Mojoli
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Guido Tavazzi
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy.
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3
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Forbes LM, Bull TM, Lahm T, Sisson T, O’Gean K, Lawley JS, Hunter K, Levine BD, Lovering A, Roach RC, Subudhi AW, Cornwell WK. Right ventricular performance during acute hypoxic exercise. J Physiol 2024:10.1113/JP284943. [PMID: 38409819 PMCID: PMC11345882 DOI: 10.1113/jp284943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 02/01/2024] [Indexed: 02/28/2024] Open
Abstract
Acute hypoxia increases pulmonary arterial (PA) pressures, though its effect on right ventricular (RV) function is controversial. The objective of this study was to characterize exertional RV performance during acute hypoxia. Ten healthy participants (34 ± 10 years, 7 males) completed three visits: visits 1 and 2 included non-invasive normoxic (fraction of inspired oxygen (F i O 2 ${F_{{\mathrm{i}}{{\mathrm{O}}_{\mathrm{2}}}}}$ ) = 0.21) and isobaric hypoxic (F i O 2 ${F_{{\mathrm{i}}{{\mathrm{O}}_{\mathrm{2}}}}}$ = 0.12) cardiopulmonary exercise testing (CPET) to determine normoxic/hypoxic maximal oxygen uptake (V ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ ). Visit 3 involved invasive haemodynamic assessments where participants were randomized 1:1 to either Swan-Ganz or conductance catheterization to quantify RV performance via pressure-volume analysis. Arterial oxygen saturation was determined by blood gas analysis from radial arterial catheterization. During visit 3, participants completed invasive submaximal CPET testing at 50% normoxicV ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ and again at 50% hypoxicV ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ (F i O 2 ${F_{{\mathrm{i}}{{\mathrm{O}}_{\mathrm{2}}}}}$ = 0.12). Median (interquartile range) values for non-invasiveV ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ values during normoxic and hypoxic testing were 2.98 (2.43, 3.66) l/min and 1.84 (1.62, 2.25) l/min, respectively (P < 0.0001). Mean PA pressure increased significantly when transitioning from rest to submaximal exercise during normoxic and hypoxic conditions (P = 0.0014). Metrics of RV contractility including preload recruitable stroke work, dP/dtmax , and end-systolic pressure increased significantly during the transition from rest to exercise under normoxic and hypoxic conditions. Ventricular-arterial coupling was maintained during normoxic exercise at 50%V ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ . During submaximal exercise at 50% of hypoxicV ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ , ventricular-arterial coupling declined but remained within normal limits. In conclusion, resting and exertional RV functions are preserved in response to acute exposure to hypoxia at anF i O 2 ${F_{{\mathrm{i}}{{\mathrm{O}}_{\mathrm{2}}}}}$ = 0.12 and the associated increase in PA pressures. KEY POINTS: The healthy right ventricle augments contractility, lusitropy and energetics during periods of increased metabolic demand (e.g. exercise) in acute hypoxic conditions. During submaximal exercise, ventricular-arterial coupling decreases but remains within normal limits, ensuring that cardiac output and systemic perfusion are maintained. These data describe right ventricular physiological responses during submaximal exercise under conditions of acute hypoxia, such as occurs during exposure to high altitude and/or acute hypoxic respiratory failure.
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Affiliation(s)
- Lindsay M. Forbes
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado, United States
| | - Todd M. Bull
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado, United States
| | - Tim Lahm
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado, United States
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado, United States
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, United States
| | - Tyler Sisson
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora CO
| | - Katie O’Gean
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora CO
| | - Justin S. Lawley
- Department of Sport Science, University of Innsbruck, Innsbruck Austria
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Kendall Hunter
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora CO
| | - Benjamin D. Levine
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
- Texas Health Presbyterian Hospital, Institute for Exercise and Environmental Medicine, Dallas TX
| | | | - Robert C. Roach
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado, United States
| | - Andrew W. Subudhi
- Department of Physiology, University of Colorado, Colorado Springs, Colorado, United States
| | - William K. Cornwell
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora CO
- Division of Cardiology, Department of Medicine. University of Colorado, Aurora, Colorado, United States
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Protti I, van den Enden A, Van Mieghem NM, Meuwese CL, Meani P. Looking Back, Going Forward: Understanding Cardiac Pathophysiology from Pressure-Volume Loops. BIOLOGY 2024; 13:55. [PMID: 38275731 PMCID: PMC10813445 DOI: 10.3390/biology13010055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024]
Abstract
Knowing cardiac physiology is essential for health care professionals working in the cardiovascular field. Pressure-volume loops (PVLs) offer a unique understanding of the myocardial working and have become pivotal in complex pathophysiological scenarios, such as profound cardiogenic shock or when mechanical circulatory supports are implemented. This review provides a comprehensive summary of the left and right ventricle physiology, based on the PVL interpretation.
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Affiliation(s)
- Ilaria Protti
- Department of Intensive Care and Cardiology, Cardiovascular Institute, Thoraxcenter, Erasmus University Medical Center, 3012 Rotterdam, The Netherlands; (I.P.)
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
| | - Antoon van den Enden
- Department of Intensive Care and Cardiology, Cardiovascular Institute, Thoraxcenter, Erasmus University Medical Center, 3012 Rotterdam, The Netherlands; (I.P.)
| | - Nicolas M. Van Mieghem
- Department of Intensive Care and Cardiology, Cardiovascular Institute, Thoraxcenter, Erasmus University Medical Center, 3012 Rotterdam, The Netherlands; (I.P.)
| | - Christiaan L. Meuwese
- Department of Intensive Care and Cardiology, Cardiovascular Institute, Thoraxcenter, Erasmus University Medical Center, 3012 Rotterdam, The Netherlands; (I.P.)
| | - Paolo Meani
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, 6229 Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences, Maastricht University, 6211 Maastricht, The Netherlands
- Thoracic Research Center, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, 85-094 Bydgoszcz, Poland
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5
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Chen Z, Chung Y, Cheng J, Huang C, Chen S, Lin L, Lai H, Wu C. Right Ventricular-Vascular Uncoupling Predicts Pulmonary Hypertension in Clinically Diagnosed Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2024; 13:e030025. [PMID: 38156457 PMCID: PMC10863814 DOI: 10.1161/jaha.123.030025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 09/11/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Pulmonary hypertension (PH) is highly prevalent in patients with heart failure with preserved ejection fraction (HFpEF), and it is a strong predictor of adverse outcomes. We aimed to determine possible echocardiographic parameters to predict the presence of PH in patients with HFpEF. METHODS AND RESULTS A total of 113 patients with HFpEF were prospectively enrolled from November 2017 to July 2022. The patients underwent invasive cardiac catheterization and simultaneous echocardiography at rest and during exercise. The parameters indicating right ventricle-pulmonary artery uncoupling, including tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) and tricuspid annular systolic velocity (TAS')/PASP were calculated. Receiver operating characteristic curve analysis was used to determine the optimal cut-off points of TAPSE/PASP and TAS'/PASP to differentiate patients with HFpEF with PH from those without PH. Sixty-eight patients with HFpEF with PH and 45 without PH were included. Those with PH had lower TAPSE/PASP and TAS'/PASP at rest and during exercise compared with those without PH. Both resting/stress TAPSE/PASP and TAS'/PASP were correlated with rest/exercise pulmonary capillary wedge pressure and mean pulmonary artery pressure. In multivariable regression analysis, TAPSE/PASP remained a significant predictor of exercise pulmonary capillary wedge pressure and mean pulmonary artery pressure. In receiver operating characteristic curve analysis, the optimal cut-off points of TAPSE/PASP and TAS'/PASP to differentiate patients with HFpEF with PH from those without PH were ≤0.62 and ≤0.47, respectively. CONCLUSIONS Right ventricle-pulmonary artery uncoupling is closely correlated with abnormal rest/exercise hemodynamics (pulmonary capillary wedge pressure and mean pulmonary artery pressure) in patients with HFpEF. TAPSE/PASP and TAS'/PASP can be useful parameters to detect PH in patients with HFpEF.
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Affiliation(s)
- Zheng‐Wei Chen
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
- Division of Cardiology, Department of Internal MedicineNational Taiwan University Hospital, Yun‐Lin BranchDou‐LiuTaiwan
- Graduate Institute of Clinical Medicine, College of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Yi‐Wei Chung
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
- Graduate Institute of Clinical Medicine, College of MedicineNational Taiwan UniversityTaipeiTaiwan
- Division of Cardiology, Department of Internal MedicineNational Taiwan University Hospital, Hsin‐Chu BranchHsin‐ChuTaiwan
| | - Jen‐Fang Cheng
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
| | - Chen‐Yu Huang
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
- Division of Cardiology, Department of Internal MedicineCathay General HospitalTaipeiTaiwan
| | - Ssu‐Yuan Chen
- Department of Physical Medicine & RehabilitationFu Jen Catholic University Hospital and Fu Jen Catholic University School of MedicineNew Taipei CityTaiwan
- Department of Physical Medicine & RehabilitationNational Taiwan University Hospital and National Taiwan University College of MedicineTaipeiTaiwan
| | - Lian‐Yu Lin
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
| | - Hung‐Chun Lai
- Department of Psychiatry, Shuang Ho HospitalTaipei Medical UniversityNew Taipei CityTaiwan
| | - Cho‐Kai Wu
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
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6
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Häfner F, Kindt A, Strobl K, Förster K, Heydarian M, Gonzalez E, Schubert B, Kraus Y, Dalla Pozza R, Flemmer AW, Ertl-Wagner B, Dietrich O, Stoecklein S, Tello K, Hilgendorff A. MRI pulmonary artery flow detects lung vascular pathology in preterms with lung disease. Eur Respir J 2023; 62:2202445. [PMID: 37678954 PMCID: PMC10749508 DOI: 10.1183/13993003.02445-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 07/24/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Pulmonary vascular disease (PVD) affects the majority of preterm neonates with bronchopulmonary dysplasia (BPD) and significantly determines long-term mortality through undetected progression into pulmonary hypertension. Our objectives were to associate characteristics of pulmonary artery (PA) flow and cardiac function with BPD-associated PVD near term using advanced magnetic resonance imaging (MRI) for improved risk stratification. METHODS Preterms <32 weeks postmenstrual age (PMA) with/without BPD were clinically monitored including standard echocardiography and prospectively enrolled for 3 T MRI in spontaneous sleep near term (AIRR (Attention to Infants at Respiratory Risks) study). Semi-manual PA flow quantification (phase-contrast MRI; no BPD n=28, mild BPD n=35 and moderate/severe BPD n=25) was complemented by cardiac function assessment (cine MRI). RESULTS We identified abnormalities in PA flow and cardiac function, i.e. increased net forward volume right/left ratio, decreased mean relative area change and pathological right end-diastolic volume, to sensitively detect BPD-associated PVD while correcting for PMA (leave-one-out area under the curve 0.88, sensitivity 0.80 and specificity 0.81). We linked these changes to increased right ventricular (RV) afterload (RV-arterial coupling (p=0.02), PA mid-systolic notching (t2; p=0.015) and cardiac index (p=1.67×10-8)) and correlated echocardiographic findings. Identified in moderate/severe BPD, we successfully applied the PA flow model in heterogeneous mild BPD cases, demonstrating strong correlation of PVD probability with indicators of BPD severity, i.e. duration of mechanical ventilation (rs=0.63, p=2.20×10-4) and oxygen supplementation (rs=0.60, p=6.00×10-4). CONCLUSIONS Abnormalities in MRI PA flow and cardiac function exhibit significant, synergistic potential to detect BPD-associated PVD, advancing the possibilities of risk-adapted monitoring.
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Affiliation(s)
- Friederike Häfner
- Institute for Lung Health and Immunity and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Center Munich, Member of the German Center for Lung Research (DZL), Munich, Germany
- Center for Comprehensive Developmental Care (CDeCLMU) at the interdisciplinary Social Pediatric Center (iSPZ Hauner), Haunersches Children's Hospital, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
- F. Häfner and A. Kindt contributed equally to this study
| | - Alida Kindt
- Metabolomics and Analytics Centre, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
- F. Häfner and A. Kindt contributed equally to this study
| | - Kathrin Strobl
- Center for Comprehensive Developmental Care (CDeCLMU) at the interdisciplinary Social Pediatric Center (iSPZ Hauner), Haunersches Children's Hospital, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Kai Förster
- Center for Comprehensive Developmental Care (CDeCLMU) at the interdisciplinary Social Pediatric Center (iSPZ Hauner), Haunersches Children's Hospital, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
- Division of Neonatology, University Children's Hospital Dr v. Hauner and Perinatal Center, University Hospital, Ludwig Maximilian University Munich, Munich Germany
| | - Motaharehsadat Heydarian
- Institute for Lung Health and Immunity and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Center Munich, Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Erika Gonzalez
- Institute for Lung Health and Immunity and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Center Munich, Member of the German Center for Lung Research (DZL), Munich, Germany
- Center for Comprehensive Developmental Care (CDeCLMU) at the interdisciplinary Social Pediatric Center (iSPZ Hauner), Haunersches Children's Hospital, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Benjamin Schubert
- Institute of Computational Biology, Helmholtz Center Munich, Munich, Germany
| | - Yvonne Kraus
- Center for Comprehensive Developmental Care (CDeCLMU) at the interdisciplinary Social Pediatric Center (iSPZ Hauner), Haunersches Children's Hospital, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Robert Dalla Pozza
- Department of Pediatric Cardiology, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Andreas W Flemmer
- Division of Neonatology, University Children's Hospital Dr v. Hauner and Perinatal Center, University Hospital, Ludwig Maximilian University Munich, Munich Germany
| | - Birgit Ertl-Wagner
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, ON, Canada
| | - Olaf Dietrich
- Department of Radiology, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Sophia Stoecklein
- Department of Radiology, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Khodr Tello
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Anne Hilgendorff
- Institute for Lung Health and Immunity and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Center Munich, Member of the German Center for Lung Research (DZL), Munich, Germany
- Center for Comprehensive Developmental Care (CDeCLMU) at the interdisciplinary Social Pediatric Center (iSPZ Hauner), Haunersches Children's Hospital, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
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Heerdt PM, Martin-Flores M, Oakland HT, Joseph P, Singh I. Integrating Right Ventricular Pressure Waveform Analysis With Two-Point Volume Measurement for Quantification of Systolic and Diastolic Function: Experimental Validation and Clinical Application. J Cardiothorac Vasc Anesth 2023; 37:1929-1937. [PMID: 37422337 PMCID: PMC10529383 DOI: 10.1053/j.jvca.2023.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/20/2023] [Accepted: 06/06/2023] [Indexed: 07/10/2023]
Abstract
OBJECTIVE To define in an experimental model the variance, accuracy, precision, and concordance of single-beat measures of right ventricular (RV) contractility and diastolic capacitance relative to conventional reference standards, and apply the methods to a clinical data set. DESIGN A retrospective, observational analysis of recorded pressure waveforms and RV volume measurements. SETTING At a university laboratory. PARTICIPANTS Archived data from previous studies of anesthetized swine and awake patients undergoing clinically-indicated right-heart catheterization. INTERVENTIONS Recording of RV pressure with simultaneous measurement of RV volume by conductance (swine) or 3-dimensional (3D) echocardiography (humans) during changes in contractility and/or loading conditions. MEASUREMENTS AND MAIN RESULTS Using experimental data, single-beat measures of RV contractility quantified as end-systolic elastance, and diastolic capacitance quantified as the predicted volume at an end-diastolic pressure of 15 mmHg (V15), were compared to multi-beat, preload- variant, reference standards using correlation, Bland-Altman analysis, and 4-quadrant concordance testing. This analysis indicated that the methods were not directly interchangeable with reference standards, but were sufficiently robust to suggest potential clinical utility. Clinical application supported this potential by demonstrating enhanced assessment of the response to inhaled nitric oxide in patients undergoing diagnostic right-heart catheterization. CONCLUSIONS Study results supported the possibility of integrating automated RV pressure analysis with RV volume measured by 3D echocardiography to create a comprehensive assessment of RV systolic and diastolic function at the bedside.
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Affiliation(s)
- Paul M Heerdt
- Department of Anesthesiology, Applied Hemodynamics, Yale School of Medicine, New Haven, CT.
| | - Manuel Martin-Flores
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, NY
| | - Hannah T Oakland
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT
| | - Phillip Joseph
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT
| | - Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT
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8
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Richter MJ, Douschan P, Fortuni F, Gall H, Ghofrani HA, Keranov S, Kremer N, Kriechbaum SD, Rako ZA, Rieth AJ, da Rocha BB, Seeger W, Zedler D, Yildiz S, Yogeswaran A, Tello K. Echocardiographic pressure-strain loop-derived stroke work of the right ventricle: validation against the gold standard. ESC Heart Fail 2023; 10:3209-3215. [PMID: 37415381 PMCID: PMC10567659 DOI: 10.1002/ehf2.14453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 05/08/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023] Open
Abstract
AIMS Commercially available integrated software for echocardiographic measurement of stroke work (SW) is increasingly used for the right ventricle, despite a lack of validation. We sought to assess the validity of this method [echo-based myocardial work (MW) module] vs. gold-standard invasive right ventricular (RV) pressure-volume (PV) loops. METHODS AND RESULTS From the prospectively recruiting EXERTION study (NCT04663217), we included 42 patients [34 patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) and 8 patients with absence of cardiopulmonary disease] with RV echocardiography and invasive PV catheterization. Echocardiographic SW was assessed as RV global work index (RVGWI) generated via the integrated pressure-strain MW software. Invasive SW was calculated as the area bounded by the PV loop. An additional parameter derived from the MW module, RV global wasted work (RVGWW), was correlated with PV loop measures. RVGWI significantly correlated with invasive PV loop-derived RV SW in the overall cohort [rho = 0.546 (P < 0.001)] and the PAH/CTEPH subgroup [rho = 0.568 (P < 0.001)]. Overall, RVGWW correlated with invasive measures of arterial elastance (Ea), the ratio of end-systolic elastance (Ees)/Ea, and end-diastolic elastance (Eed) significantly. CONCLUSIONS Integrated echo measurement of pressure-strain loop-derived SW correlates with PV loop-based assessment of RV SW. Wasted work correlates with invasive measures of load-independent RV function. Given the methodological and anatomical challenges of RV work assessment, evolution of this approach by incorporating more elaborated echo analysis data and an RV reference curve might improve its reliability to mirror invasively assessed RV SW.
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Affiliation(s)
- Manuel J. Richter
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)Klinikstrasse 3235392GiessenGermany
| | - Philipp Douschan
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)Klinikstrasse 3235392GiessenGermany
- Division of Pulmonology, Department of Internal MedicineMedical University of GrazGrazAustria
| | - Federico Fortuni
- Department of CardiologySan Giovanni Battista HospitalFolignoItaly
- Department of CardiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Henning Gall
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)Klinikstrasse 3235392GiessenGermany
| | - Hossein A. Ghofrani
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)Klinikstrasse 3235392GiessenGermany
- Department of PneumologyKerckhoff Heart, Rheuma and Thoracic CenterBad NauheimGermany
- Department of MedicineImperial College LondonLondonUK
| | - Stanislav Keranov
- Department of Cardiology and AngiologyUniversity of GiessenGiessenGermany
| | - Nils Kremer
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)Klinikstrasse 3235392GiessenGermany
| | - Steffen D. Kriechbaum
- Department of CardiologyHeart and Thorax Center, Campus Kerckhoff, University of GiessenBad NauheimGermany
| | - Zvonimir A. Rako
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)Klinikstrasse 3235392GiessenGermany
| | - Andreas J. Rieth
- Department of CardiologyHeart and Thorax Center, Campus Kerckhoff, University of GiessenBad NauheimGermany
| | - Bruno Brito da Rocha
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)Klinikstrasse 3235392GiessenGermany
| | - Werner Seeger
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)Klinikstrasse 3235392GiessenGermany
| | - Daniel Zedler
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)Klinikstrasse 3235392GiessenGermany
| | - Selin Yildiz
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)Klinikstrasse 3235392GiessenGermany
| | - Athiththan Yogeswaran
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)Klinikstrasse 3235392GiessenGermany
| | - Khodr Tello
- Department of Internal MedicineJustus‐Liebig‐University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL)Klinikstrasse 3235392GiessenGermany
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9
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Johnson S, Sommer N, Cox-Flaherty K, Weissmann N, Ventetuolo CE, Maron BA. Pulmonary Hypertension: A Contemporary Review. Am J Respir Crit Care Med 2023; 208:528-548. [PMID: 37450768 PMCID: PMC10492255 DOI: 10.1164/rccm.202302-0327so] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/14/2023] [Indexed: 07/18/2023] Open
Abstract
Major advances in pulmonary arterial hypertension, pulmonary hypertension (PH) associated with lung disease, and chronic thromboembolic PH cast new light on the pathogenetic mechanisms, epidemiology, diagnostic approach, and therapeutic armamentarium for pulmonary vascular disease. Here, we summarize key basic, translational, and clinical PH reports, emphasizing findings that build on current state-of-the-art research. This review includes cutting-edge progress in translational pulmonary vascular biology, with a guide to the diagnosis of patients in clinical practice, incorporating recent PH definition revisions that continue emphasis on early detection of disease. PH management is reviewed including an overview of the evolving considerations for the approach to treatment of PH in patients with cardiopulmonary comorbidities, as well as a discussion of the groundbreaking sotatercept data for the treatment of pulmonary arterial hypertension.
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Affiliation(s)
- Shelsey Johnson
- The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical Care, Boston University School of Medicine, Boston, Massachusetts
- Department of Pulmonary and Critical Care Medicine and
| | - Natascha Sommer
- Excellence Cluster Cardiopulmonary Institute, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | | | - Norbert Weissmann
- Excellence Cluster Cardiopulmonary Institute, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | - Corey E. Ventetuolo
- Department of Medicine and
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island
| | - Bradley A. Maron
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
- Department of Cardiology and Department of Pulmonary, Allergy, Sleep, and Critical Care Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland; and
- The University of Maryland-Institute for Health Computing, Bethesda, Maryland
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10
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Wu Y, Tian P, Liang L, Chen Y, Feng J, Huang B, Huang L, Zhao X, Wang J, Guan J, Li X, Zhang Y, Zhang J. Combined use of right ventricular coupling and pulmonary arterial elastance as a comprehensive stratification approach for right ventricular function. Clin Transl Sci 2023; 16:1582-1593. [PMID: 37326126 PMCID: PMC10499407 DOI: 10.1111/cts.13568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/10/2023] [Accepted: 05/29/2023] [Indexed: 06/17/2023] Open
Abstract
Right ventricular (RV)-pulmonary arterial uncoupling is the consequence of increased afterload and/or decreased RV contractility. However, the combination of arterial elastance (Ea) and end-systolic elastance (Ees)/Ea ratio to assess RV function is unclear. We hypothesized that the combination of both could comprehensively assess RV function and refine risk stratification. The median Ees/Ea ratio (0.80) and Ea (0.59 mmHg/mL) were used to classify 124 patients with advanced heart failure into four groups. RV systolic pressure differential was defined as end-systolic pressure (ESP) minus beginning-systolic pressure (BSP). Patients among different subsets showed dissimilar New York Heart Association functional class (V = 0.303, p = 0.010), distinct tricuspid annular plane systolic excursion/ pulmonary artery systolic pressure (mm/mmHg; 0.65 vs. 0.44 vs. 0.32 vs. 0.26, p < 0.001), and diverse prevalence of pulmonary hypertension (33.3% vs. 35% vs. 90% vs. 97.6%, p < 0.001). By multivariate analysis, Ees/Ea ratio (hazard ratio [HR] 0.225, p = 0.004) and Ea (HR 2.194, p = 0.003) were independently associated with event-free survival. Patients with Ees/Ea ratio greater than or equal to 0.80 and Ea less than 0.59 mmHg/mL had better outcomes (p < 0.05). In patients with Ees/Ea ratio greater than or equal to 0.80, those with Ea greater than or equal to 0.59 mmHg/mL had a higher adverse outcome risk (p < 0.05). Ees/Ea ratio less than or equal to 0.80 was associated with adverse outcomes, even when Ea was less than 0.59 mmHg/mL (p < 0.05). Approximately 86% of patients with ESP-BSP greater than 5 mmHg had an Ees/Ea ratio less than or equal to 0.80 and/or an Ea greater than or equal to 0.59 mmHg/mL (V = 0.336, p = 0.001). Combined use of Ees/Ea ratio and Ea could be a comprehensive approach to assessing RV function and predicting outcomes. An exploratory analysis demonstrated that Ees/Ea ratio and Ea might be roughly estimated based on RV systolic pressure differential.
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Affiliation(s)
- Yihang Wu
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Pengchao Tian
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Lin Liang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Yuyi Chen
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Jiayu Feng
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Boping Huang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Liyan Huang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Xuemei Zhao
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Jing Wang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Jingyuan Guan
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Xinqing Li
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Yuhui Zhang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Jian Zhang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
- Key Laboratory of Clinical Research for Cardiovascular MedicationsNational Health CommitteeBeijingChina
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11
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Tello K, Naeije R, de Man F, Guazzi M. Pathophysiology of the right ventricle in health and disease: an update. Cardiovasc Res 2023; 119:1891-1904. [PMID: 37463510 DOI: 10.1093/cvr/cvad108] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/14/2023] [Accepted: 05/02/2023] [Indexed: 07/20/2023] Open
Abstract
The contribution of the right ventricle (RV) to cardiac output is negligible in normal resting conditions when pressures in the pulmonary circulation are low. However, the RV becomes relevant in healthy subjects during exercise and definitely so in patients with increased pulmonary artery pressures both at rest and during exercise. The adaptation of RV function to loading rests basically on an increased contractility. This is assessed by RV end-systolic elastance (Ees) to match afterload assessed by arterial elastance (Ea). The system has reserve as the Ees/Ea ratio or its imaging surrogate ejection fraction has to decrease by more than half, before the RV undergoes an increase in dimensions with eventual increase in filling pressures and systemic congestion. RV-arterial uncoupling is accompanied by an increase in diastolic elastance. Measurements of RV systolic function but also of diastolic function predict outcome in any cause pulmonary hypertension and heart failure with or without preserved left ventricular ejection fraction. Pathobiological changes in the overloaded RV include a combination of myocardial fibre hypertrophy, fibrosis and capillary rarefaction, a titin phosphorylation-related displacement of myofibril tension-length relationships to higher pressures, a metabolic shift from mitochondrial free fatty acid oxidation to cytoplasmic glycolysis, toxic lipid accumulation, and activation of apoptotic and inflammatory signalling pathways. Treatment of RV failure rests on the relief of excessive loading.
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Affiliation(s)
- Khodr Tello
- Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Klinikstrasse 36, 35392 Giessen, Germany
| | - Robert Naeije
- Pathophysiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium
| | - Frances de Man
- Pulmonary Medicine, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Marco Guazzi
- Cardiology Division, San Paolo University Hospital, University of Milano, Milano, Italy
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12
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Caccamo M, Harrell FE, Hemnes AR. Evolution and optimization of clinical trial endpoints and design in pulmonary arterial hypertension. Pulm Circ 2023; 13:e12271. [PMID: 37554146 PMCID: PMC10405062 DOI: 10.1002/pul2.12271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/10/2023] Open
Abstract
Selection of endpoints for clinical trials in pulmonary arterial hypertension (PAH) is challenging because of the small numbers of patients and the changing expectations of patients, clinicians, and regulators in this evolving therapy area. The most commonly used primary endpoint in PAH trials has been 6-min walk distance (6MWD), leading to the approval of several targeted therapies. However, single surrogate endpoints such as 6MWD or hemodynamic parameters may not correlate with clinical outcomes. Composite endpoints of clinical worsening have been developed to reflect patients' overall condition more accurately, although there is no standard definition of worsening. Recently there has been a shift to composite endpoints assessing clinical improvement, and risk scores developed from registry data are increasingly being used. Biomarkers are another area of interest, although brain natriuretic peptide and its N-terminal prohormone are the only markers used for risk assessment or as endpoints in PAH. A range of other genetic, metabolic, and immunologic markers is currently under investigation, along with conventional and novel imaging modalities. Patient-reported outcomes are an increasingly important part of evaluating new therapies, and several PAH-specific tools are now available. In the future, alternative statistical techniques and trial designs, such as patient enrichment strategies, will play a role in evaluating PAH-targeted therapies. In addition, modern sequencing techniques, imaging analyses, and high-dimensional statistical modeling/machine learning may reveal novel markers that can play a role in the diagnosis and monitoring of PAH.
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Affiliation(s)
- Marco Caccamo
- Division of CardiologyWVU Heart and Vascular InstituteMorgantownWest VirginiaUSA
| | - Frank E. Harrell
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary, and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
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13
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He Q, Lin Y, Zhu Y, Gao L, Ji M, Zhang L, Xie M, Li Y. Clinical Usefulness of Right Ventricle-Pulmonary Artery Coupling in Cardiovascular Disease. J Clin Med 2023; 12:2526. [PMID: 37048609 PMCID: PMC10095537 DOI: 10.3390/jcm12072526] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/02/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Right ventricular-pulmonary artery coupling (RV-PA coupling) refers to the relationship between RV contractility and RV afterload. Normal RV-PA coupling is maintained only when RV function and pulmonary vascular resistance are appropriately matched. RV-PA uncoupling occurs when RV contractility cannot increase to match RV afterload, resulting in RV dysfunction and right heart failure. RV-PA coupling plays an important role in the pathophysiology and progression of cardiovascular diseases. Therefore, early and accurate evaluation of RV-PA coupling is of great significance for a patient's condition assessment, clinical decision making, risk stratification, and prognosis judgment. RV-PA coupling can be assessed by using invasive or noninvasive approaches. The aim of this review was to summarize the pathological mechanism and evaluation methods of RV-PA coupling, the advantages and disadvantages of each method, and the application value of RV-PA coupling in various cardiovascular diseases.
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Affiliation(s)
- Qing He
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Yixia Lin
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Ye Zhu
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Lang Gao
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Mengmeng Ji
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Li Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Mingxing Xie
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Yuman Li
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
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14
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van den Enden AJM, Meuwese CL, Van Mieghem NM. Changing biventricular mechanics during thrombectomy for intermediate high-risk pulmonary embolism. Eur Heart J 2023; 44:1001. [PMID: 36130335 PMCID: PMC10011330 DOI: 10.1093/eurheartj/ehac508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Antoon J M van den Enden
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, office Nt-645, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Christiaan L Meuwese
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, office Nt-645, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
- Department of Intensive Care Adults, Erasmus University Medical Center, Rotterdam, The Netherlands
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15
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Marchetta S, Verbelen T, Claessen G, Quarck R, Delcroix M, Godinas L. A Comprehensive Assessment of Right Ventricular Function in Chronic Thromboembolic Pulmonary Hypertension. J Clin Med 2022; 12:47. [PMID: 36614845 PMCID: PMC9821031 DOI: 10.3390/jcm12010047] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
While chronic thromboembolic pulmonary hypertension (CTEPH) results from macroscopic and microscopic obstruction of the pulmonary vascular bed, the function of the right ventricle (RV) and increased RV afterload are the main determinants of its symptoms and prognosis. In this review, we assess RV function in patients diagnosed with CTEPH with a focus on the contributions of RV afterload and dysfunction to the pathogenesis of this disease. We will also discuss changes in RV function and geometry in response to treatment, including medical therapy, pulmonary endarterectomy, and balloon pulmonary angioplasty.
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Affiliation(s)
| | - Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Guido Claessen
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Rozenn Quarck
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chonic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
| | - Marion Delcroix
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chonic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
- Department of Pneumology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Laurent Godinas
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chonic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
- Department of Pneumology, University Hospitals Leuven, 3000 Leuven, Belgium
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16
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Jabagi H, Nantsios A, Ruel M, Mielniczuk LM, Denault AY, Sun LY. A standardized definition for right ventricular failure in cardiac surgery patients. ESC Heart Fail 2022; 9:1542-1552. [PMID: 35266332 PMCID: PMC9065859 DOI: 10.1002/ehf2.13870] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/28/2022] [Accepted: 02/17/2022] [Indexed: 11/07/2022] Open
Abstract
Right ventricular failure (RVF) is a significant cause of mortality and morbidity after cardiac surgery. Despite its prognostic importance, RVF remains under investigated and without a universally accepted definition in the perioperative setting. We foresee that the provision of a standardized perioperative definition for RVF based on practical and objective criteria will help to improve quality of care through early detection and facilitate the generalization of RVF research to advance this field. This article provides an overview of RVF aetiology, pathophysiology, current diagnostic modalities, as well as a summary of existing RVF definitions. This is followed by our proposal for a standardized definition of perioperative RVF, one that captures RV structural and functional abnormalities through a multimodal approach based on anatomical, echocardiographic, and haemodynamic criteria that are readily available in the perioperative setting (Central Image).
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Affiliation(s)
- Habib Jabagi
- Division of Cardiac Surgery, Valley Health System, Ridgewood, NJ, USA
| | - Alex Nantsios
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Lisa M Mielniczuk
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - André Y Denault
- Department of Anesthesiology and Critical Care Division, Montreal Heart Institute and Université de Montréal, Montreal, QC, Canada
| | - Louise Y Sun
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Room H-2206, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Cardiovascular Research Program, Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada
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17
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Brener MI, Masoumi A, Ng VG, Tello K, Bastos MB, Cornwell WK, Hsu S, Tedford RJ, Lurz P, Rommel KP, Kresoja KP, Nagueh SF, Kanwar MK, Kapur NK, Hiremath G, Sarraf M, Van Den Enden AJM, Van Mieghem NM, Heerdt PM, Hahn RT, Kodali SK, Sayer GT, Uriel N, Burkhoff D. Invasive Right Ventricular Pressure-Volume Analysis: Basic Principles, Clinical Applications, and Practical Recommendations. Circ Heart Fail 2022; 15:e009101. [PMID: 34963308 PMCID: PMC8766922 DOI: 10.1161/circheartfailure.121.009101] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Right ventricular pressure-volume (PV) analysis characterizes ventricular systolic and diastolic properties independent of loading conditions like volume status and afterload. While long-considered the gold-standard method for quantifying myocardial chamber performance, it was traditionally only performed in highly specialized research settings. With recent advances in catheter technology and more sophisticated approaches to analyze PV data, it is now more commonly used in a variety of clinical and research settings. Herein, we review the basic techniques for PV loop measurement, analysis, and interpretation with the aim of providing readers with a deeper understanding of the strengths and limitations of PV analysis. In the second half of the review, we detail key scenarios in which right ventricular PV analysis has influenced our understanding of clinically relevant topics and where the technique can be applied to resolve additional areas of uncertainty. All told, PV analysis has an important role in advancing our understanding of right ventricular physiology and its contribution to cardiovascular function in health and disease.
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Affiliation(s)
- Michael I Brener
- Division of Cardiology, Columbia University Medical Center, New York, NY (M.I.B., A.M., V.G.N., R.T.H., S.K.K., G.T.S., N.U., D.B.)
| | - Amirali Masoumi
- Division of Cardiology, Columbia University Medical Center, New York, NY (M.I.B., A.M., V.G.N., R.T.H., S.K.K., G.T.S., N.U., D.B.)
| | - Vivian G Ng
- Division of Cardiology, Columbia University Medical Center, New York, NY (M.I.B., A.M., V.G.N., R.T.H., S.K.K., G.T.S., N.U., D.B.)
| | - Khodr Tello
- Department of Internal Medicine, Justus Liebig Universitat Giessen, Germany (K.T.)
| | - Marcelo B Bastos
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands (M.B.B., A.J.M.V.D.E., N.M.V.M.)
| | - William K Cornwell
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora (W.K.C.)
| | - Steven Hsu
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (S.H.)
| | - Ryan J Tedford
- Division of Cardiology, Medical University of South Carolina, Charleston (R.J.T.)
| | - Philipp Lurz
- Division of Cardiology, Heart Center, University of Leipzig, Germany (P.L., K.-P.R., K.-P.K.)
| | - Karl-Philipp Rommel
- Division of Cardiology, Heart Center, University of Leipzig, Germany (P.L., K.-P.R., K.-P.K.)
| | - Karl-Patrik Kresoja
- Division of Cardiology, Heart Center, University of Leipzig, Germany (P.L., K.-P.R., K.-P.K.)
| | - Sherif F Nagueh
- Section of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, TX (S.F.N.)
| | - Manreet K Kanwar
- Cardiovascular Institute, Alleghany Health Network, Pittsburgh, PA (M.K.K.)
| | - Navin K Kapur
- Cardiovascular Center and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (N.K.K.)
| | - Gurumurthy Hiremath
- Division of Pediatric Cardiology, University of Minnesota Masonic Children's Hospital, Minneapolis (G.H.)
| | | | - Antoon J M Van Den Enden
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands (M.B.B., A.J.M.V.D.E., N.M.V.M.)
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands (M.B.B., A.J.M.V.D.E., N.M.V.M.)
| | - Paul M Heerdt
- Division of Anesthesiology, Yale University School of Medicine, New Haven, CT (P.M.H.)
| | - Rebecca T Hahn
- Division of Cardiology, Columbia University Medical Center, New York, NY (M.I.B., A.M., V.G.N., R.T.H., S.K.K., G.T.S., N.U., D.B.)
| | - Susheel K Kodali
- Division of Cardiology, Columbia University Medical Center, New York, NY (M.I.B., A.M., V.G.N., R.T.H., S.K.K., G.T.S., N.U., D.B.)
| | - Gabriel T Sayer
- Division of Cardiology, Columbia University Medical Center, New York, NY (M.I.B., A.M., V.G.N., R.T.H., S.K.K., G.T.S., N.U., D.B.)
| | - Nir Uriel
- Division of Cardiology, Columbia University Medical Center, New York, NY (M.I.B., A.M., V.G.N., R.T.H., S.K.K., G.T.S., N.U., D.B.)
| | - Daniel Burkhoff
- Division of Cardiology, Columbia University Medical Center, New York, NY (M.I.B., A.M., V.G.N., R.T.H., S.K.K., G.T.S., N.U., D.B.)
- Cardiovascular Research Foundation, New York, NY (D.B.)
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18
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Kremer N, Rako Z, Douschan P, Gall H, Ghofrani HA, Grimminger F, Guth S, Naeije R, Rieth A, Schulz R, Seeger W, Tedford RJ, Vadász I, Vanderpool R, Wiedenroth CB, Richter MJ, Tello K. Unmasking right ventricular-arterial uncoupling during fluid challenge in pulmonary hypertension. J Heart Lung Transplant 2021; 41:345-355. [PMID: 34972609 DOI: 10.1016/j.healun.2021.11.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/20/2021] [Accepted: 11/30/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Patients with pulmonary hypertension (PH) frequently show preserved right ventricular (RV) function at rest. However, volume challenge may uncover pending RV dysfunction. We aimed to assess the physiological and prognostic impact of RV-pulmonary arterial (RV-PA) uncoupling during volume challenge in patients with precapillary PH. METHODS We prospectively assessed 32 patients with PH (pulmonary arterial hypertension, n = 27; inoperable chronic thromboembolic disease, n = 5) and 4 controls using invasive pressure-volume (PV) catheterization. PV loops were recorded during preload reduction (balloon occlusion of inferior vena cava; baseline) and acute volume loading (200 ml saline in 20 s). Contractility (multi-beat end-systolic elastance [Ees]), arterial elastance (Ea), and RV-PA coupling (Ees/Ea) were obtained at baseline and at maximum volume loading (MVL). RESULTS Median [interquartile range] time to MVL was 19 [18-22] s. Ees/Ea significantly declined from baseline (0.89 [0.69-1.23]) to MVL (0.16 [0.12-0.34]; p < 0.001) in patients with PH but remained stable in controls (baseline: 1.08 [0.94-1.80]; MVL: 1.01 [0.80-2.49]; p = 0.715). The same pattern was observed for Ees, while Ea remained unchanged. The percent decline of RV-PA coupling (ΔEes/Ea) during fluid challenge was significantly associated with pulmonary resting hemodynamics, RV ejection fraction (RVEF), and RV end-diastolic volume. Kaplan-Meier analysis revealed that patients with PH who had a smaller ΔEes/Ea (<-65%) had a significantly better prognosis (log-rank p = 0.0389). In multivariate Cox regression analysis, clinical worsening was predicted by ΔEes/Ea (hazard ratio: 0.96 [95% confidence interval: 0.93-1.00]) and RVEF (hazard ratio: 0.95 [95% confidence interval: 0.92-0.98]). CONCLUSIONS Assessment of PV loops during fluid challenge uncovers exhausted RV coupling reserve with severely reduced contractility in PH. RV-PA uncoupling during volume challenge can be predicted by pulmonary resting hemodynamics and RVEF. RV-PA uncoupling during fluid challenge and RVEF (as a noninvasive correlate) are predictors of clinical worsening. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT03403868 (January 19, 2018).
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Affiliation(s)
- Nils Kremer
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Zvonimir Rako
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Philipp Douschan
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany; Division of Pulmonology, Department of Internal Medicine and Ludwig Boltzmann Institute for Lung Vascular Research, Medical University of Graz, Graz, Austria
| | - Henning Gall
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Hossein A Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany; Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany; Department of Medicine, Imperial College London, London, UK
| | - Friedrich Grimminger
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany; Institute for Lung Health, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | | | - Andreas Rieth
- Department of Cardiology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Rainer Schulz
- Institute of Physiology, Justus-Liebig-University Giessen, Giessen, Germany
| | - Werner Seeger
- Institute for Lung Health, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Ryan J Tedford
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - István Vadász
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Rebecca Vanderpool
- Division of Translational and Regenerative Medicine, University of Arizona, Tucson, Arizona
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Manuel J Richter
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Khodr Tello
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany.
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19
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Naeije R, Richter MJ, Rubin LJ. The physiologic basis of pulmonary arterial hypertension. Eur Respir J 2021; 59:13993003.02334-2021. [PMID: 34737219 PMCID: PMC9203839 DOI: 10.1183/13993003.02334-2021] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/18/2021] [Indexed: 11/05/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare dyspnea-fatigue syndrome caused by a progressive increase in pulmonary vascular resistance (PVR) and eventual right ventricular (RV) failure. In spite of extensive pulmonary vascular remodeling, lung function in PAH is generally well preserved, with hyperventilation and increased physiologic dead space, but minimal changes in lung mechanics and only mild to moderate hypoxemia and hypocapnia. Hypoxemia is mainly caused by a low mixed venous PO2 from a decreased cardiac output. Hypocapnia is mainly caused by an increased chemosensitivity. Exercise limitation in PAH is cardiovascular rather than ventilatory or muscular. The extent of pulmonary vascular disease in PAH is defined by multipoint pulmonary vascular pressure-flow relationships with a correction for hematocrit. Pulsatile pulmonary vascular pressure-flow relationships in PAH allow for the assessment of RV hydraulic load. This analysis is possible either in the frequency-domain or in the time-domain. The RV in PAH adapts to increased afterload by an increased contractility to preserve its coupling to the pulmonary circulation. When this homeometric mechanism is exhausted, the RV dilates to preserve flow output by an additional heterometric mechanism. Right heart failure is then diagnosed by imaging of increased right heart dimensions and clinical systemic congestion signs and symptoms. The coupling of the RV to the pulmonary circulation is assessed by the ratio of end-systolic to arterial elastances, but these measurements are difficult. Simplified estimates of RV-PA coupling can be obtained by magnetic resonance or echocardiographic imaging of ejection fraction.
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Affiliation(s)
| | - Manuel J Richter
- Department of Internal Medicine, Justus Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Lewis J Rubin
- University of California, San Diego, La Jolla, CA, USA
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20
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Singh I, Oakland H, Elassal A, Heerdt PM. Defining end-systolic pressure for single-beat estimation of right ventricle-pulmonary artery coupling: simple… but not really. ERJ Open Res 2021; 7:00219-2021. [PMID: 34435035 PMCID: PMC8381254 DOI: 10.1183/23120541.00219-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/25/2021] [Indexed: 11/05/2022] Open
Abstract
Surrogates of right ventricle (RV) end-systolic pressure (ESP) used to determine RV-pulmonary artery coupling vary across studies. ESP using point of maximal time varying elastance provides most accurate estimate of actual ESP. https://bit.ly/3xuqX3B.
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Affiliation(s)
- Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Dept of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Hannah Oakland
- Division of Pulmonary, Critical Care, and Sleep Medicine, Dept of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Ahmed Elassal
- Dept of Anaesthesiology, Division of Applied Hemodynamics, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Paul M Heerdt
- Dept of Anaesthesiology, Division of Applied Hemodynamics, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
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