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Heerdt PM, Kheyfets VO, Oakland HT, Joseph P, Singh I. Right Ventricular Pressure Waveform Analysis-Clinical Relevance and Future Directions. J Cardiothorac Vasc Anesth 2024; 38:2433-2445. [PMID: 39025682 DOI: 10.1053/j.jvca.2024.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 06/02/2024] [Accepted: 06/15/2024] [Indexed: 07/20/2024]
Abstract
Continuous measurement of pressure in the right atrium and pulmonary artery has commonly been used to monitor right ventricular function in critically ill and surgical patients. This approach is largely based upon the assumption that right atrial and pulmonary arterial pressures provide accurate surrogates for diastolic filling and peak right ventricular pressures, respectively. However, due to both technical and physiologic factors, this assumption is not always true. Accordingly, recent studies have begun to emphasize the potential clinical value of also measuring right ventricular pressure at the bedside. This has highlighted both past and emerging research demonstrating the utility of analyzing not only the amplitude of right ventricular pressure but also the shape of the pressure waveform. This brief review summarizes data demonstrating that combining conventional measurements of right ventricular pressure with variables derived from waveform shape allows for more comprehensive and ideally continuous bedside assessment of right ventricular function, particularly when combined with stroke volume measurement or 3D echocardiography, and discusses the potential use of right ventricular pressure analysis in computational models for evaluating cardiac function.
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Affiliation(s)
- Paul M Heerdt
- Department of Anesthesiology, Applied Hemodynamics, Yale School of Medicine, New Haven, CT.
| | - Vitaly O Kheyfets
- Department of Pediatrics-Critical Care Medicine, University of Colorado - Anschutz Medical Campus, Denver, CO
| | - 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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Meinert-Krause JP, Mechelinck M, Hein M, Habigt MA. Intrinsic mechanisms of right ventricular autoregulation. Sci Rep 2024; 14:9356. [PMID: 38654031 DOI: 10.1038/s41598-024-59787-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024] Open
Abstract
To elucidate the adaptation of the right ventricle to acute and intermittently sustained afterload elevation, targeted preload reductions and afterload increases were implemented in a porcine model involving 12 pigs. Preload reduction was achieved via balloon occlusion of the inferior vena cava before, immediately and 5 min after acute afterload elevation induced by pulmonary artery occlusion or thromboxane A2 analog (U46619) infusion. Ventricular response was monitored by registration of pressure-volume (PV) loops using a conductance catheter. The end-systolic pressure-volume relationship (ESPVR) during pure preload reduction was adequately described by linear regression (mean and SEM slope of ESPVR (Ees) 0.414 ± 0.064 mmHg/ml), reflecting the classical Frank-Starling mechanism (FSM). The ESPVR during acute afterload elevation exhibited a biphasic trajectory with significantly distinct slopes (mean and SEM Ees bilin1: 1.256 ± 0.066 mmHg ml; Ees bilin2: 0.733 ± 0.063 mmHg ml, p < 0.001). The higher slope during the first phase in the absence of ventricular dilation could be explained by a reduced amount of shortening deactivation (SDA). The changes in PV-loops during the second phase were similar to those observed with a preload intervention. The persistent increase in afterload resulted in an increase in the slopes of ESPVR and preload recruitable stroke work (PRSW) with a slight decrease in filling state, indicating a relevant Anrep effect. This effect became more pronounced after 5 min or TXA infusion. This study demonstrates, for the first time, the relevance of intrinsic mechanisms of cardiac autoregulation in the right ventricle during the adaptation to load. The SDA, FSM, and Anrep effect could be differentiated and occurred successively, potentially with some overlap. Notably, the Anrep effect serves to prevent ventricular dilation.
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Affiliation(s)
- Jan-Pit Meinert-Krause
- Faculty of Medicine, Anaesthesiology Clinic, University Hospital RWTH Aachen, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Mare Mechelinck
- Faculty of Medicine, Anaesthesiology Clinic, University Hospital RWTH Aachen, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Marc Hein
- Faculty of Medicine, Anaesthesiology Clinic, University Hospital RWTH Aachen, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Moriz A Habigt
- Faculty of Medicine, Anaesthesiology Clinic, University Hospital RWTH Aachen, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
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Shima H, Tsujino I, Nakamura J, Nakaya T, Sugimoto A, Sato T, Watanabe T, Ohira H, Suzuki M, Tsuneta S, Chiba Y, Murayama M, Yokota I, Konno S. Exploratory analysis of the accuracy of echocardiographic parameters for the assessment of right ventricular function and right ventricular-pulmonary artery coupling. Pulm Circ 2024; 14:e12368. [PMID: 38774813 PMCID: PMC11108640 DOI: 10.1002/pul2.12368] [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: 12/04/2023] [Revised: 03/12/2024] [Accepted: 04/07/2024] [Indexed: 05/24/2024] Open
Abstract
Echocardiography is a widely used modality for the assessment of right ventricular (RV) function; however, few studies have comprehensively compared the accuracy of echocardiographic parameters using invasively obtained reference values. Therefore, this exploratory study aimed to compare the accuracy of echocardiographic parameters of RV function and RV-pulmonary artery (PA) coupling. We calculated four indices of RV function (end-systolic elastance [Ees] for systolic function [contractility], τ for relaxation, and β and end-diastolic elastance [Eed] for stiffness), and an index of RV-PA coupling (Ees/arterial elastance [Ea]), using pressure catheterization, cardiac magnetic resonance imaging, and a single-beat method. We then compared the correlations of RV indices with echocardiographic parameters. In 63 participants (54 with pulmonary hypertension (PH) and nine without PH), Ees and τ correlated with several echocardiographic parameters, such as RV diameter and area, but the correlations were moderate (|correlation coefficients (ρ)| < 0.5 for all parameters). The correlations of β and Eed with echocardiographic parameters were weak, with |ρ| < 0.4. In contrast, Ees/Ea closely correlated with RV free wall longitudinal strain (RVFW-LS)/estimated systolic PA pressure (eSPAP) (ρ = -0.72). Ees/Ea also correlated with tricuspid annular plane systolic excursion/eSPAP, RV diameter, and RV end-systolic area, with |ρ | >0.65. In addition, RVFW-LS/eSPAP yielded high sensitivity (0.84) and specificity (0.75) for detecting reduced Ees/Ea. The present study indicated a limited accuracy of echocardiographic parameters in assessing RV systolic and diastolic function. In contrast to RV function, they showed high accuracy for assessing RV-PA coupling, with RVFW-LS/eSPAP exhibiting the highest accuracy.
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Affiliation(s)
- Hideki Shima
- Department of Respiratory Medicine, Faculty of MedicineHokkaido UniversitySapporoJapan
| | - Ichizo Tsujino
- Department of Respiratory Medicine, Faculty of MedicineHokkaido UniversitySapporoJapan
- Division of Respiratory and Cardiovascular Innovative Research, Faculty of MedicineHokkaido UniversitySapporoJapan
| | - Junichi Nakamura
- Department of Respiratory Medicine, Faculty of MedicineHokkaido UniversitySapporoJapan
| | - Toshitaka Nakaya
- Department of Respiratory Medicine, Faculty of MedicineHokkaido UniversitySapporoJapan
| | - Ayako Sugimoto
- Department of Respiratory Medicine, Faculty of MedicineHokkaido UniversitySapporoJapan
| | - Takahiro Sato
- Department of Respiratory Medicine, Faculty of MedicineHokkaido UniversitySapporoJapan
- Division of Respiratory and Cardiovascular Innovative Research, Faculty of MedicineHokkaido UniversitySapporoJapan
| | - Taku Watanabe
- Department of Respiratory Medicine, Faculty of MedicineHokkaido UniversitySapporoJapan
| | - Hiroshi Ohira
- Department of Respiratory Medicine, Faculty of MedicineHokkaido UniversitySapporoJapan
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of MedicineHokkaido UniversitySapporoJapan
| | - Satonori Tsuneta
- Department of Diagnostic and Interventional RadiologyHokkaido University HospitalSapporoJapan
| | - Yasuyuki Chiba
- Department of Cardiovascular MedicineHokkaido University Graduate School of MedicineSapporoJapan
| | - Michito Murayama
- Department of Medical Laboratory Science, Faculty of Health SciencesHokkaido UniversitySapporoJapan
- Diagnostic Center for SonographyHokkaido University HospitalSapporoJapan
| | - Isao Yokota
- Department of BiostatisticsHokkaido University Graduate School of MedicineSapporoJapan
| | - Satoshi Konno
- Department of Respiratory Medicine, Faculty of MedicineHokkaido UniversitySapporoJapan
- Division of Respiratory and Cardiovascular Innovative Research, Faculty of MedicineHokkaido UniversitySapporoJapan
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Sandeep B, Cheng H, Yan Y, Huang X, Wu Q, Gao K, Xiao Z. Right ventricle-pulmonary artery coupling in pulmonary artery hypertension its measurement and pharmacotherapy. Curr Probl Cardiol 2024; 49:102425. [PMID: 38311275 DOI: 10.1016/j.cpcardiol.2024.102425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 01/29/2024] [Indexed: 02/09/2024]
Abstract
The right ventricular (RV) function correlates with prognosis in severe pulmonary artery hypertension (PAH) but which metric of it is most clinically relevant is still uncertain. Clinical methods to estimate RV function from simplified pressure volume loops correlate with disease severity but the clinical relevance has not been assessed. Evaluation of right ventricle pulmonary artery coupling in pulmonary hypertensive patients may help to elucidate the mechanisms of right ventricular failure and may also help to identify patients at risk or guide the timing of therapeutic interventions in pulmonary hypertension. Complete evaluation of RV failure requires echocardiographic or magnetic resonance imaging, and right heart catheterization measurements. Treatment of RV failure in PAH relies on decreasing afterload with drugs targeting pulmonary circulation; fluid management to optimize ventricular diastolic interactions; and inotropic interventions to reverse cardiogenic shock. The ability to relate quantitative metrics of RV function in pulmonary artery hypertension to clinical outcomes can provide a powerful tool for management. Such metrics could also be utilized in the future as surrogate endpoints for outcomes and evaluation of response to therapies. This review of literature gives an insight on RV-PA coupling associated with PAH, its types of measurement and pharmacological treatment.
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Affiliation(s)
- Bhushan Sandeep
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan 610017, China
| | - Han Cheng
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan 610017, China
| | - Yifan Yan
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan 610017, China
| | - Xin Huang
- Department of Anesthesiology, West China Hospital of Medicine, Sichuan University, Sichuan 610017, China
| | - Qinghui Wu
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan 610017, China
| | - Ke Gao
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan 610017, China.
| | - Zongwei Xiao
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan 610017, China
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Tarras E, Khosla A, Heerdt PM, Singh I. Right Heart Failure in the Intensive Care Unit: Etiology, Pathogenesis, Diagnosis, and Treatment. J Intensive Care Med 2023:8850666231216889. [PMID: 38031338 DOI: 10.1177/08850666231216889] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Right heart (RH) failure carries a high rate of morbidity and mortality. Patients who present with RH failure often exhibit complex aberrant cardio-pulmonary physiology with varying presentations. The treatment of RH failure almost always requires care and management from an intensivist. Treatment options for RH failure patients continue to evolve rapidly with multiple options available, including different pharmacotherapies and mechanical circulatory support devices that target various components of the RH circulatory system. An understanding of the normal RH circulatory physiology, treatment, and support options for the RH failure patients is necessary for all intensivists to improve outcomes. The purpose of this review is to provide clinical guidance on the diagnosis and management of RH failure within the intensive care unit setting, and to highlight the different pathophysiological manifestations of RH failure, its hemodynamics, and treatment options available at the disposal of the intensivist.
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Affiliation(s)
- Elizabeth Tarras
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Akhil Khosla
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Paul M Heerdt
- Department of Anesthesiology, Division of Applied Hemodynamics, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - 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, USA
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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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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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Isotani Y, Amiya E, Hatano M, Kiriyama H, Uehara M, Ishida J, Tsuji M, Bujo C, Narita K, Ishii S, Kakuda N, Minatsuki S, Yagi H, Saito A, Numata G, Yamada T, Kurihara T, Suzuki T, Komuro I. A new assessment method for right ventricular diastolic function using right heart catheterization by pressure-volume loop. Physiol Rep 2023; 11:e15751. [PMID: 37394657 PMCID: PMC10315326 DOI: 10.14814/phy2.15751] [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: 03/08/2023] [Revised: 05/26/2023] [Accepted: 05/26/2023] [Indexed: 07/04/2023] Open
Abstract
Diastolic stiffness coefficient (β) and end-diastolic elastance (Eed) are ventricular-specific diastolic parameters. However, the diastolic function of right ventricle had not been investigated sufficiently due to the lack of established evaluation method. We evaluated the validity of these parameters calculated using only data of right heart catheterization (RHC) and assessed it in patients with restrictive cardiomyopathy (RCM) and cardiac amyloidosis. We retrospectively analyzed 46 patients with heart failure who underwent RHC within 10 days of cardiac magnetic resonance (CMR). Right ventricular end-diastolic volume and end-systolic volume were calculated using only RHC data, which were found to be finely correlated with those obtained from CMR. β and Eed calculated by this method were also significantly correlated with those derived from conventional method using CMR. By this method, β and Eed were significantly higher in RCM with amyloidosis group than dilated cardiomyopathy group. In addition, the β and Eed calculated by our method were finely correlated with E/A ratio on echocardiography. We established an easy method to estimate β and Eed of right ventricle from only RHC. The method finely demonstrated right ventricular diastolic dysfunction in patients with RCM and amyloidosis.
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Affiliation(s)
- Yoshitaka Isotani
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
- Department of Therapeutic Strategy for Heart Failure, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
- Department of Advanced Medical Center for Heart Failure, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Hiroyuki Kiriyama
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Masae Uehara
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Masaki Tsuji
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Chie Bujo
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
- Department of Therapeutic Strategy for Heart Failure, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Koichi Narita
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Satoshi Ishii
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Nobutaka Kakuda
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Shun Minatsuki
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Hiroki Yagi
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Akihito Saito
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Genri Numata
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Takanobu Yamada
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Takahiro Kurihara
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
| | - Tatsuya Suzuki
- Electrical Engineering Program, Graduate School of Science and TechnologyMeiji UniversityKawasakiJapan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of MedicineThe University of TokyoBunkyo‐kuJapan
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9
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Doyle M, Rayarao G, Biederman RWW. The sine transform is the sine qua non of the pulmonary and systemic pressure relationship. Front Cardiovasc Med 2023; 10:1120330. [PMID: 37304951 PMCID: PMC10250723 DOI: 10.3389/fcvm.2023.1120330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Assessment of therapeutic interventions in patients with pulmonary arterial hypertension (PAH) suffers from several commonly encountered limitations: (1) patient studies are often too small and short-term to provide definitive conclusions, (2) there is a lack of a universal set of metrics to adequately assess therapy and (3) while clinical treatments focus on management of symptoms, there remain many cases of early loss of life in a seemingly arbitrary distribution. Here we provide a unified approach to assess right and left pressure relationships in PAH and pulmonary hypertension (PH) patients by developing linear models informed by the observation of Suga and Sugawa that pressure generation in the ventricle (right or left) approximately follows a single lobe of a sinusoid. We sought to identify a set of cardiovascular variables that either linearly or via a sine transformation related to systolic pulmonary arterial pressure (PAPs) and systemic systolic blood pressure (SBP). Importantly, both right and left cardiovascular variables are included in each linear model. Using non-invasively obtained cardiovascular magnetic resonance (CMR) image metrics the approach was successfully applied to model PAPs in PAH patients with an r2 of 0.89 (p < 0.05) and SBP with an r2 of 0.74 (p < 0.05). Further, the approach clarified the relationships that exist between PAPs and SBP separately for PAH and PH patients, and these relationships were used to distinguish PAH vs. PH patients with good accuracy (68%, p < 0.05). An important feature of the linear models is that they demonstrate that right and left ventricular conditions interact to generate PAPs and SBP in PAH patients, even in the absence of left-sided disease. The models predicted a theoretical right ventricular pulsatile reserve that in PAH patients was shown to be predictive of the 6 min walk distance (r2 = 0.45, p < 0.05). The linear models indicate a physically plausible mode of interaction between right and left ventricles and provides a means of assessing right and left cardiac status as they relate to PAPs and SBP. The linear models have potential to allow assessment of the detailed physiologic effects of therapy in PAH and PH patients and may thus permit cross-over of knowledge between PH and PAH clinical trials.
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Affiliation(s)
- Mark Doyle
- Department Cardiology, Cardiovascular MRI, Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA, United States
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10
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Gaertner M, Glocker R, Glocker F, Hopf H. Pressure-based beat-to-beat right ventricular ejection fraction and Tau from continuous measured ventricular pressures in COVID-19 ARDS patients. Pulm Circ 2023; 13:e12179. [PMID: 36718290 PMCID: PMC9817071 DOI: 10.1002/pul2.12179] [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: 07/04/2022] [Revised: 10/08/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022] Open
Abstract
We evaluated pressure-based right ventricular ejection fraction (RVEF) and diastolic isovolumetric relaxation time constant (Tau) from continuously (up to 30 days) invasive measured right ventricular pressures in mechanically ventilated patients with severe COVID-19 acute respiratory distress syndrome (ARDS). We retrospectively calculated beat-to-beat ejection fraction from right ventricular pressures and dp/dt maximum and minimum in 39 patients treated between October 1st, 2020 and June 30th, 2021. After performing a stepwise logistic regression with survival as a dependent variable, we divided the patients into survivors and nonsurvivors based on their 60-day mortality. Independent outcome variables were the values of RVEF and Tau over time after insertion of the right ventricular probe along with right ventricular systolic and diastolic pressures (RVSP) and the estimated pulmonary artery diastolic pressure (ePAD). RVEF increased significantly over time in the survivors (estimate: 0.354; 95% confidence interval, CI: 0.18-0.53; p < 0.001) but remained unchanged in the nonsurvivors. Tau increased significantly in the nonsurvivors (estimate: 0.001; 95% CI: 0.0004-0.0018; p < 0.002) but not in the survivors. On the last measurement day, RVSP and ePAD were significantly lower while RVEF was significantly higher in the survivors compared to the nonsurvivors. In COVID-19 ARDS patient's, calculation of beat-to-beat RVEF and Tau from continuously invasive measured right ventricular pressures seems to unravel contrary trends in RVEF with an increase in the surviving and a decrease in the nonsurviving patients. Tau remained unchanged in the surviving but increased in the nonsurviving patients over time.
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Affiliation(s)
- Matthias Gaertner
- Department of AnesthesiologyDüsseldorf University HospitalDüsseldorfGermany
| | | | | | - Hans‐Bernd Hopf
- emka MEDICAL GmbHAschaffenburgGermany,Department of Anaesthesia, Perioperative Medicine and Interdisciplinary Intensive Care Medicine, ECLS‐ECMO Center LangenAsklepios Klinik LangenLangenGermany
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11
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Raza F, Kozitza C, Lechuga C, Seiter D, Corrado P, Merchant M, Dharmavaram N, Korcarz C, Eldridge M, Francois C, Wieben O, Chesler N. Multimodality Deep Phenotyping Methods to Assess Mechanisms of Poor Right Ventricular-Pulmonary Artery Coupling. FUNCTION 2022; 3:zqac022. [PMID: 35774590 PMCID: PMC9228647 DOI: 10.1093/function/zqac022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/01/2022] [Accepted: 04/20/2022] [Indexed: 01/07/2023] Open
Abstract
Deep phenotyping of pulmonary hypertension (PH) with multimodal diagnostic exercise interventions can lead to early focused therapeutic interventions. Herein, we report methods to simultaneously assess pulmonary impedance, differential biventricular myocardial strain, and right ventricular:pulmonary arterial (RV:PA) uncoupling during exercise, which we pilot in subjects with suspected PH. As proof-of-concept, we show that four subjects with different diagnoses [pulmonary arterial hypertension (PAH); chronic thromboembolic disease (CTEPH); PH due to heart failure with preserved ejection fraction (PH-HFpEF); and noncardiac dyspnea (NCD)] have distinct patterns of response to exercise. RV:PA coupling assessment with exercise was highest-to-lowest in this order: PAH > CTEPH > PH-HFpEF > NCD. Input impedance (Z0) with exercise was highest in precapillary PH (PAH, CTEPH), followed by PH-HFpEF and NCD. Characteristic impedance (ZC) tended to decline with exercise, except for the PH-HFpEF subject (initial Zc increase at moderate workload with subsequent decrease at higher workload with augmentation in cardiac output). Differential myocardial strain was normal in PAH, CTEPH, and NCD subjects and lower in the PH-HFpEF subject in the interventricular septum. The combination of these metrics allowed novel insights into mechanisms of RV:PA uncoupling. For example, while the PH-HFpEF subject had hemodynamics comparable to the NCD subject at rest, with exercise coupling dropped precipitously, which can be attributed (by decreased myocardial strain of interventricular septum) to poor support from the left ventricle (LV). We conclude that this deep phenotyping approach may distinguish afterload sensitive vs. LV-dependent mechanisms of RV:PA uncoupling in PH, which may lead to novel therapeutically relevant insights.
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Affiliation(s)
- Farhan Raza
- Department of Medicine, Cardiovascular Division, University of Wisconsin-Madison, Wisconsin, USA
| | - Callyn Kozitza
- Biomedical Engineering, University of Wisconsin-Madison, Wisconsin, USA
| | - Chris Lechuga
- Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center and Department of Biomedical Engineering, University of California, Irvine, USA
| | - Daniel Seiter
- Medical Physics, University of Wisconsin-Madison, Wisconsin, USA
| | - Philip Corrado
- Medical Physics, University of Wisconsin-Madison, Wisconsin, USA
| | - Mohammed Merchant
- Department of Medicine, Cardiovascular Division, University of Wisconsin-Madison, Wisconsin, USA
| | - Naga Dharmavaram
- Department of Medicine, Cardiovascular Division, University of Wisconsin-Madison, Wisconsin, USA
| | - Claudia Korcarz
- Department of Medicine, Cardiovascular Division, University of Wisconsin-Madison, Wisconsin, USA
| | - Marlowe Eldridge
- Department of Pediatrics, University of Wisconsin-Madison, Wisconsin, USA
| | | | - Oliver Wieben
- Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center and Department of Biomedical Engineering, University of California, Irvine, USA
| | - Naomi Chesler
- Medical Physics, University of Wisconsin-Madison, Wisconsin, USA
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12
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Shima H, Nakaya T, Tsujino I, Nakamura J, Sugimoto A, Sato T, Watanabe T, Ohira H, Suzuki M, Kato M, Yokota I, Konno S. Accuracy of Swan‒Ganz catheterization‐based assessment of right ventricular function: Validation study using high‐fidelity micromanometry‐derived values as reference. Pulm Circ 2022; 12:e12078. [PMID: 35514782 PMCID: PMC9063972 DOI: 10.1002/pul2.12078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/15/2022] [Accepted: 04/06/2022] [Indexed: 11/14/2022] Open
Abstract
Right ventricular (RV) function critically affects the outcomes of patients with pulmonary hypertension (PH). Pressure wave analysis using Swan‒Ganz catheterization (SG‐cath) allows for the calculation of indices of RV function. However, the accuracy of these indices has not been validated. In the present study, we calculated indices of systolic and diastolic RV functions using SG‐cath‐derived pressure recordings in patients with suspected or confirmed PH. We analyzed and validated the accuracies of three RV indices having proven prognostic values, that is, end‐systolic elastance (Ees)/arterial elastance (Ea), β (stiffness constant), and end‐diastolic elastance (Eed), using high‐fidelity micromanometry‐derived data as reference. We analyzed 73 participants who underwent SG‐cath for the diagnosis or evaluation of PH. In this study, Ees/Ea was calculated via the single‐beat pressure method using [1.65 × (mean pulmonary arterial pressure) − 7.79] as end‐systolic pressure. SG‐cath‐derived Ees/Ea, β, and Eed were 0.89 ± 0.69 (mean ± standard deviation), 0.027 ± 0.002, and 0.16 ± 0.02 mmHg/ml, respectively. The mean differences (limits of agreement) between SG‐cath and micromanometry‐derived data were 0.13 (0.99, −0.72), 0.002 (0.020, −0.013), and 0.04 (0.20, −0.12) for Ees/Ea, β, and Eed, respectively. The intraclass correlation coefficients of the indices derived from the two catheterizations were 0.76, 0.71, and 0.57 for Ees/Ea, β, and Eed, respectively. In patients with confirmed or suspected PH, SG‐cath‐derived RV indices, especially Ees/Ea and β, exhibited a good correlation with micromanometry‐derived reference values.
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Affiliation(s)
- Hideki Shima
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Toshitaka Nakaya
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Ichizo Tsujino
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
- Division of Respiratory and Cardiovascular Innovative Research Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Junichi Nakamura
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Ayako Sugimoto
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Takahiro Sato
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
- Division of Respiratory and Cardiovascular Innovative Research Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Taku Watanabe
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Hiroshi Ohira
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine Hokkaido University Japan
| | - Satoshi Konno
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
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13
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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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14
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Ahmed M, Zaghloul N, Zimmerman P, Casanova NG, Sun X, Song JH, Hernon VR, Sammani S, Rischard F, Rafikova O, Rafikov R, Makino A, Kempf CL, Camp SM, Wang J, Desai AA, Lussier Y, Yuan JXJ, Garcia JG. Endothelial eNAMPT drives EndMT and preclinical PH: rescue by an eNAMPT-neutralizing mAb. Pulm Circ 2021; 11:20458940211059712. [PMID: 34790349 PMCID: PMC8591779 DOI: 10.1177/20458940211059712] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/25/2021] [Indexed: 12/03/2022] Open
Abstract
Pharmacologic interventions to halt/reverse the vascular remodeling and right ventricular dysfunction in pulmonary arterial hypertension (PAH) remains an unmet need. We previously demonstrated extracellular nicotinamide phosphoribosyltransferase (eNAMPT) as a DAMP (damage-associated molecular pattern protein) contributing to PAH pathobiology via TLR4 ligation. We examined the role of endothelial cell (EC)-specific eNAMPT in experimental PH and an eNAMPT-neutralizing mAb as a therapeutic strategy to reverse established PH. Hemodynamic/echocardiographic measurements and tissue analyses were performed in Sprague Dawley rats exposed to 10% hypoxia/Sugen (three weeks) followed by return to normoxia and weekly intraperitoneal delivery of the eNAMPT mAb (1 mg/kg). WT C57BL/6J mice and conditional EC-cNAMPTec-/- mice were exposed to 10% hypoxia (three weeks). Biochemical and RNA sequencing studies were performed on rat PH lung tissues and human PAH PBMCs. Hypoxia/Sugen-exposed rats exhibited multiple indices of severe PH (right ventricular systolic pressure, Fulton index), including severe vascular remodeling, compared to control rats. PH severity indices and plasma levels of eNAMPT, IL-6, and TNF-α were all significantly attenuated by eNAMPT mAb neutralization. Compared to hypoxia-exposed WT mice, cNAMPTec-/- KO mice exhibited significantly reduced PH severity and evidence of EC to mesenchymal transition (EndMT). Finally, biochemical and RNAseq analyses revealed eNAMPT mAb-mediated rectification of dysregulated inflammatory signaling pathways (TLR/NF-κB, MAP kinase, Akt/mTOR) and EndMT in rat PH lung tissues and human PAH PBMCs. These studies underscore EC-derived eNAMPT as a key contributor to PAH pathobiology and support the eNAMPT/TLR4 inflammatory pathway as a highly druggable therapeutic target to reduce PH severity and reverse PAH.
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Affiliation(s)
- Mohamed Ahmed
- Department of Pediatrics, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Nahla Zaghloul
- Department of Pediatrics, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Prisca Zimmerman
- Department of Pediatrics, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Nancy G. Casanova
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Xiaoguang Sun
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Jin H. Song
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Vivian Reyes Hernon
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Saad Sammani
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Franz Rischard
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Olga Rafikova
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Ruslan Rafikov
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Ayako Makino
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Carrie L. Kempf
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Sara M. Camp
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Jian Wang
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
- State Key Laboratory of Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Ankit A. Desai
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Yves Lussier
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Jason X.-J. Yuan
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Joe G.N. Garcia
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
- State Key Laboratory of Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
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15
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Dufva MJ, Ivy D, Campbell K, Lam A, Rauff A, Breeman KTN, Douwes JM, Berger RMF, Kheyfets VO, Hunter K. Ventricular-vascular coupling is predictive of adverse clinical outcome in paediatric pulmonary arterial hypertension. Open Heart 2021; 8:openhrt-2021-001611. [PMID: 34583983 PMCID: PMC8479945 DOI: 10.1136/openhrt-2021-001611] [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: 02/01/2021] [Accepted: 08/27/2021] [Indexed: 11/25/2022] Open
Abstract
Aims Ventricular–vascular coupling, the ratio between the right ventricle’s contractile state (Ees) and its afterload (Ea), may be a useful metric in the management of paediatric pulmonary arterial hypertension (PAH). In this study we assess the prognostic capacity of the ventricular–vascular coupling ratio (Ees/Ea) derived using right ventricular (RV) pressure alone in children with PAH. Methods One hundred and thirty paediatric patients who were diagnosed with PAH via right heart catheterisation were retrospectively reviewed over a 10-year period. Maximum RV isovolumic pressure and end-systolic pressure were estimated using two single-beat methods from Takeuchi et al (Ees/Ea_(Takeuchi)) and from Kind et al (Ees/Ea_(Kind)) and used with an estimate of end-systolic pressure to compute ventricular–vascular coupling from pressure alone. Patients were identified as either idiopathic/hereditary PAH or associated PAH (IPAH/HPAH and APAH, respectively). Haemodynamic data, clinical functional class and clinical worsening outcomes—separated into soft (mild) and hard (severe) event categories—were assessed. Adverse soft events included functional class worsening, syncopal event, hospitalisation due to a proportional hazard-related event and haemoptysis. Hard events included death, transplantation, initiation of prostanoid therapy and hospitalisation for atrial septostomy and Pott’s shunt. Cox proportional hazard modelling was used to assess whether Ees/Ea was predictive of time-to-event. Results In patients with IPAH/HPAH, Ees/Ea_(Kind) and Ees/Ea_(Takeuchi) were both independently associated with time to hard event (p=0.003 and p=0.001, respectively) and when adjusted for indexed pulmonary vascular resistance (p=0.032 and p=0.013, respectively). Neither Ees/Ea_(Kind) nor Ees/Ea_(Takeuchi) were associated with time to soft event. In patients with APAH, neither Ees/Ea_(Kind) nor Ees/Ea_(Takeuchi) were associated with time to hard event or soft event. Conclusions Ees/Ea derived from pressure alone is a strong independent predictor of adverse outcome and could be a potential powerful prognostic tool for paediatric PAH.
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Affiliation(s)
- Melanie J Dufva
- Bioengineering, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA .,Cardiology, Children's Hospital Colorado, Aurora, Colorado, USA.,Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Dunbar Ivy
- Cardiology, Children's Hospital Colorado, Aurora, Colorado, USA.,Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Kristen Campbell
- Cardiology, Children's Hospital Colorado, Aurora, Colorado, USA.,Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Aimee Lam
- Bioengineering, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA.,Cardiology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Adam Rauff
- Bioengineering, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Bioengineering, University of Utah Health, Salt Lake City, Utah, USA
| | - Karel T N Breeman
- Cardiology, Children's Hospital Colorado, Aurora, Colorado, USA.,Paediatric Cardiology, University Medical Center Groningen Department of Cardiology, Groningen, The Netherlands
| | - Johannes M Douwes
- Paediatric Cardiology, University Medical Center Groningen Department of Cardiology, Groningen, The Netherlands
| | - Rolf M F Berger
- Paediatric Cardiology, University Medical Center Groningen Department of Cardiology, Groningen, The Netherlands
| | - Vitaly Oleg Kheyfets
- Bioengineering, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA.,Cardiology, Children's Hospital Colorado, Aurora, Colorado, USA.,Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Kendall Hunter
- Bioengineering, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA.,Cardiology, Children's Hospital Colorado, Aurora, Colorado, USA.,Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
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16
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Elassal A, Steppan J, Charania S, Santhanam L, Singh I, Heerdt PM. Pressure-based estimation of right ventricular ejection fraction: Validation as a clinically relevant target for drug development in a rodent model of pulmonary hypertension. J Pharmacol Toxicol Methods 2021; 112:107102. [PMID: 34245885 DOI: 10.1016/j.vascn.2021.107102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/02/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
Depressed right ventricular ejection fraction (RVEF) has clear prognostic significance in patients with pulmonary arterial hypertension (PAH). Accordingly, improvements in RVEF represent a desirable end-point in the development of PAH therapies. However, current methods for determination of RVEF require measurement of RV volume and are relatively complex and costly. Here, we validate a novel method for quantitative estimation of RVEF in rats based entirely upon analysis of readily available RV pressure waveforms that eliminates the need for simultaneous volume measurement and can be rapidly applied. Right ventricular pressure and volume (conductance catheter) measurements acquired from 15 rats (7 controls, 8 sugen/hypoxia PAH; 220-250 g) were used for the study. Over the same 10 beat interval, RVEF was directly measured from the volume signal and estimated from the pressure signal. Simultaneous measures were compared by linear regression and Bland-Altman analysis to define bias (accuracy) and precision. Measured RVEF ranged from 0.19 to 0.60 (mean 0.44 ± 0.10) and estimated from 0.19 to 0.52 (mean 0.42 ± 0.09). Across the dataset there was strong correlation (r2 = 0.813), with minimal bias (0.01) and an overall error of 20% consistent with acceptable accuracy and precision. Study results support the potential utility of a method based entirely upon analysis of the RV pressure waveform for assessing drug effects on RVEF in rat models of PAH.
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Affiliation(s)
- Ahmed Elassal
- Dept. of Anesthesiology, Division of Applied Hemodynamics, Yale University School of Medicine, USA
| | - Jochen Steppan
- Dept. of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, USA
| | - Sofia Charania
- Dept. of Anesthesiology, Division of Applied Hemodynamics, Yale University School of Medicine, USA
| | - Lakshmi Santhanam
- Depts of Anesthesiology and Critical Care Medicine, Biomedical Engineering, Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Inderjit Singh
- Dept of Medicine and Division of Pulmonary, Critical Care, and Sleep Medicine, Dept. of Medicine, Yale New Haven Hospital and Yale University School of Medicine, USA
| | - Paul M Heerdt
- Dept. of Anesthesiology, Division of Applied Hemodynamics, Yale University School of Medicine, USA.
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17
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Raza F, Kozitza C, Chybowski A, Goss KN, Berei T, Runo J, Eldridge M, Chesler N. Interferon-β-Induced Pulmonary Arterial Hypertension: Approach to Diagnosis and Clinical Monitoring. JACC Case Rep 2021; 3:1038-1043. [PMID: 34317680 PMCID: PMC8311374 DOI: 10.1016/j.jaccas.2021.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 11/23/2022]
Abstract
A 48-year-old woman who had been receiving long-term interferon-β for 8 years for multiple sclerosis developed drug-induced World Health Organization group I pulmonary arterial hypertension. Triple therapy for pulmonary arterial hypertension and suspension of interferon-β led to improvement from a high-risk to low-risk state and improvement in exercise hemodynamics, including vascular distensibility, and right ventricle–pulmonary artery coupling. (Level of Difficulty: Advanced.)
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Key Words
- 6MWD, 6-min walk distance
- BNP, B-type natriuretic peptide
- BP, blood pressure
- CMR, cardiac magnetic resonance
- CPET, cardiopulmonary exercise test
- Dlco, diffusion capacity of carbon monoxide
- ET, endothelin
- IFN, interferon
- MS, multiple sclerosis
- NYHA, New York Heart Association
- PA, pulmonary arterial
- PAH, pulmonary arterial hypertension
- RHC, right-sided heart catheterization
- RV, right ventricular
- exercise
- pulmonary hypertension
- right ventricle
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Affiliation(s)
- Farhan Raza
- Division of Cardiology, Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
- Address for correspondence: Dr. Farhan Raza, Division of Cardiology, University of Wisconsin-Madison, Hospitals and Clinics, 600 Highland Avenue, CSC-E5/582B, Madison, Wisconsin 53792, USA. @farhanraza1984
| | - Callyn Kozitza
- Department of Biomedical Engineering, University of Wisconsin, Madison, Wisconsin, USA
| | - Amy Chybowski
- Division of Pulmonary and Critical Care, Department of Medicine and Pediatrics, University of Wisconsin, Madison, Wisconsin, USA
| | - Kara N. Goss
- Division of Pulmonary and Critical Care, Department of Medicine and Pediatrics, University of Wisconsin, Madison, Wisconsin, USA
| | - Theodore Berei
- Department of Pharmacy, University of Wisconsin, Madison, Wisconsin, USA
| | - James Runo
- Division of Pulmonary and Critical Care, Department of Medicine and Pediatrics, University of Wisconsin, Madison, Wisconsin, USA
| | - Marlowe Eldridge
- Department of Pediatrics. University of Wisconsin, Madison, Wisconsin, USA
| | - Naomi Chesler
- Department of Biomedical Engineering, University of Wisconsin, Madison, Wisconsin, USA
- Department of Pediatrics. University of Wisconsin, Madison, Wisconsin, USA
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18
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Nakaya T, Tsujino I, Nakamura J, Chiba Y, Iwano H. Right ventricular pressure-volume loop produced with simultaneous application of three-dimensional echocardiography and high-fidelity micromanometry in a patient with pulmonary arterial hypertension. Echocardiography 2021; 38:805-807. [PMID: 33778995 DOI: 10.1111/echo.15032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 11/27/2022] Open
Abstract
Accurate assessment of right ventricular (RV) function has received a growing attention. Pressure-volume (PV) loop analysis is the gold standard method for evaluating RV function; however, it is not widely employed because of its invasive nature and complexity. The present report is the first to have drawn a RV PV loop in a patient with pulmonary hypertension, with a simultaneous recording of RV pressure and volume using high-fidelity micromanometry and three-dimensional echocardiography. This allows for less invasive and simple assessment of RV function, potentially promoting better understanding and management of pulmonary hypertension and other cardiovascular diseases.
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Affiliation(s)
- Toshitaka Nakaya
- Department of Respiratory Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Ichizo Tsujino
- Department of Respiratory Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Junichi Nakamura
- Department of Respiratory Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yasuyuki Chiba
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroyuki Iwano
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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19
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Sex-Related Differences in Dynamic Right Ventricular-Pulmonary Vascular Coupling in Heart Failure With Preserved Ejection Fraction. Chest 2021; 159:2402-2416. [PMID: 33388286 DOI: 10.1016/j.chest.2020.12.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/16/2020] [Accepted: 12/24/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Right ventricular (RV) dysfunction is associated with poorer outcomes in heart failure with preserved ejection fraction (HFpEF). Although female subjects are more likely to have HFpEF, male subjects have worse prognosis and resting RV function. The contribution of dynamic RV-pulmonary arterial (RV-PA) coupling between sex and its impact on peak exercise capacity (VO2) in HFpEF is not known. RESEARCH QUESTION The goal of this study was to investigate the differential effects of sex on RV-PA coupling during maximum incremental exercise in patients with HFpEF. STUDY DESIGN AND METHODS This study examined rest and exercise invasive pulmonary hemodynamics in 22 male patients with HFpEF and 27 female patients with HFpEF. To further investigate the discrepancy in RV-PA response between sex, 26 age-matched control subjects (11 male subjects and 15 female subjects) were included. Single beat analysis of RV pressure waveforms was used to determine the end-systolic elastance (Ees) and pulmonary arterial elastance. RV-PA coupling was determined as the ratio of end-systolic elastance/PA elastance. RESULTS Both HFpEF groups experienced decreased peak VO2 (% predicted). However, male patients with HFpEF experienced a greater decrement in peak VO2 compared with female patients (58 ± 16% vs 70 ± 15%; P < .05). Male patients with HFpEF had a more pronounced increase in RV afterload, Ea (1.8 ± 0.6 mm Hg/mL/m2 vs 1.3 ± 0.4 mm Hg/mL/m2; P < .05) and failed to increase RV contractility during exercise, resulting in dynamic RV-PA uncoupling (0.9 ± 0.4 vs 1.2 ± 0.4; P < .05) and subsequent reduced stroke volume index augmentation. In contrast, female patients with HFpEF were able to augment RV contractility in the face of increasing afterload, preserving RV-PA coupling during exercise. INTERPRETATION Male patients with HFpEF were more compromised regarding dynamic RV-PA uncoupling and reduced peak VO2 compared with female patients. This finding was driven by both RV contractile impairment and afterload mismatch. In contrast, female patients with HFpEF had preserved RV-PA coupling during exercise and better peak exercise VO2 compared with male patients with HFpEF.
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20
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Cheng TC, Philip JL, Tabima DM, Kumari S, Yakubov B, Frump AL, Hacker TA, Bellofiore A, Li R, Sun X, Goss KN, Lahm T, Chesler NC. Estrogen receptor-α prevents right ventricular diastolic dysfunction and fibrosis in female rats. Am J Physiol Heart Circ Physiol 2020; 319:H1459-H1473. [PMID: 33064565 PMCID: PMC7792707 DOI: 10.1152/ajpheart.00247.2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 10/09/2020] [Accepted: 10/09/2020] [Indexed: 12/24/2022]
Abstract
Although women are more susceptible to pulmonary arterial hypertension (PAH) than men, their right ventricular (RV) function is better preserved. Estrogen receptor-α (ERα) has been identified as a likely mediator for estrogen protection in the RV. However, the role of ERα in preserving RV function and remodeling during pressure overload remains poorly understood. We hypothesized that loss of functional ERα removes female protection from adverse remodeling and is permissive for the development of a maladapted RV phenotype. Male and female rats with a loss-of-function mutation in ERα (ERαMut) and wild-type (WT) littermates underwent RV pressure overload by pulmonary artery banding (PAB). At 10 wk post-PAB, WT and ERαMut demonstrated RV hypertrophy. Analysis of RV pressure waveforms demonstrated RV-pulmonary vascular uncoupling and diastolic dysfunction in female, but not male, ERαMut PAB rats. Similarly, female, but not male, ERαMut exhibited increased RV fibrosis, comprised primarily of thick collagen fibers. There was an increased protein expression ratio of TIMP metallopeptidase inhibitor 1 (Timp1) to matrix metalloproteinase 9 (Mmp9) in female ERαMut compared with WT PAB rats, suggesting less collagen degradation. RNA-sequencing in female WT and ERαMut RV revealed kallikrein-related peptidase 10 (Klk10) and Jun Proto-Oncogene (Jun) as possible mediators of female RV protection during PAB. In summary, ERα in females is protective against RV-pulmonary vascular uncoupling, diastolic dysfunction, and fibrosis in response to pressure overload. ERα appears to be dispensable for RV adaptation in males. ERα may be a mediator of superior RV adaptation in female patients with PAH.NEW & NOTEWORTHY Using a novel loss-of-function mutation in estrogen receptor-α (ERα), we demonstrate that female, but not male, ERα mutant rats display right ventricular (RV)-vascular uncoupling, diastolic dysfunction, and fibrosis following pressure overload, indicating a sex-dependent role of ERα in protecting against adverse RV remodeling. TIMP metallopeptidase inhibitor 1 (Timp1), matrix metalloproteinase 9 (Mmp9), kallikrein-related peptidase 10 (Klk10), and Jun Proto-Oncogene (Jun) were identified as potential mediators in ERα-regulated pathways in RV pressure overload.
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MESH Headings
- Animals
- Disease Models, Animal
- Estrogen Receptor alpha/genetics
- Estrogen Receptor alpha/metabolism
- Female
- Fibrillar Collagens/metabolism
- Fibrosis
- Hypertrophy, Right Ventricular/metabolism
- Hypertrophy, Right Ventricular/pathology
- Hypertrophy, Right Ventricular/physiopathology
- Hypertrophy, Right Ventricular/prevention & control
- Kallikreins/genetics
- Kallikreins/metabolism
- Male
- Mitochondria, Heart/metabolism
- Mitochondria, Heart/pathology
- Mutation
- Myocardium/metabolism
- Myocardium/pathology
- Proto-Oncogene Proteins c-jun/genetics
- Proto-Oncogene Proteins c-jun/metabolism
- Rats, Mutant Strains
- Rats, Sprague-Dawley
- Sex Factors
- Signal Transduction
- Ventricular Dysfunction, Right/metabolism
- Ventricular Dysfunction, Right/pathology
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Dysfunction, Right/prevention & control
- Ventricular Function, Right
- Ventricular Remodeling
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Affiliation(s)
- Tik-Chee Cheng
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Jennifer L Philip
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| | - Diana M Tabima
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Santosh Kumari
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin-Madison, Madison, Wisconsin
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Bakhtiyor Yakubov
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Andrea L Frump
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Timothy A Hacker
- Cardiovascular Research Center, University of Wisconsin-Madison, Madison, Wisconsin
| | - Alessandro Bellofiore
- Department of Biomedical, Chemical and Materials Engineering, San Jose State University, San Jose, California
| | - Rongbo Li
- Department of Pediatrics, University of California San Diego, La Jolla, California
| | - Xin Sun
- Department of Pediatrics, University of California San Diego, La Jolla, California
| | - Kara N Goss
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin-Madison, Madison, Wisconsin
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Tim Lahm
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Department of Cellular and Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, Indiana
- Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
| | - 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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21
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Bernardo RJ, Haddad F, Couture EJ, Hansmann G, de Jesus Perez VA, Denault AY, de Man FS, Amsallem M. Mechanics of right ventricular dysfunction in pulmonary arterial hypertension and heart failure with preserved ejection fraction. Cardiovasc Diagn Ther 2020; 10:1580-1603. [PMID: 33224775 PMCID: PMC7666917 DOI: 10.21037/cdt-20-479] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022]
Abstract
Right ventricular (RV) dysfunction is the most important determinant of survival in patients with pulmonary hypertension (PH). The manifestations of RV dysfunction not only include changes in global RV systolic function but also abnormalities in the pattern of contraction and synchrony. The effects of PH on the right ventricle have been mainly studied in patients with pulmonary arterial hypertension (PAH). However, with the demographic shift towards an aging population, heart failure with preserved ejection fraction (HFpEF) has become an important etiology of PH in recent years. There are significant differences in RV mechanics, function and adaptation between patients with PAH and HFpEF (with or without PH), which are related to different patterns of remodeling and dysfunction. Due to the unique features of the RV chamber, its connection with the main pulmonary artery and the pulmonary circulation, an understanding of the mechanics of RV function and its clinical significance is mandatory for both entities. In this review, we describe the mechanics of the pressure overloaded right ventricle. We review the different mechanical components of RV dysfunction and ventricular dyssynchrony, followed by insights via analysis of pressure-volume loop, energetics and novel blood flow patterns, such as vortex imaging. We conduct an in-depth comparison of prevalence and characteristics of RV dysfunction in HFpEF and PAH, and summarize key outcome studies. Finally, we provide a perspective on needed and expected future work in the field of RV mechanics.
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Affiliation(s)
- Roberto J. Bernardo
- Division of Pulmonary, Allergy and Critical Care, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - Francois Haddad
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Etienne J. Couture
- Department of Anesthesiology, Quebec Heart and Lung Institute, Quebec, Canada
- Intensive Care Medicine Division, Department of Medicine, Quebec Heart and Lung Institute, Quebec, Canada
- Research Center, Quebec Heart and Lung Institute, Quebec, Canada
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Vinicio A. de Jesus Perez
- Division of Pulmonary, Allergy and Critical Care, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - André Y. Denault
- Department of Anesthesiology and Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Canada
- Division of Critical Care, Centre Hospitalier de l’Université de Montréal, Montreal, Canada
| | - Frances S. de Man
- Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, PHEniX laboratory, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Myriam Amsallem
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford, CA, USA
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22
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Tello K, Richter MJ, Naeije R. Pending Right Heart Failure in Healthy Preterm-Born Subjects? Am J Respir Crit Care Med 2020; 201:1008-1009. [PMID: 31910031 PMCID: PMC7159413 DOI: 10.1164/rccm.201911-2188le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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23
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Abstract
In the late 19th century, Otto Frank published the first description of a ventricular pressure-volume diagram, thus laid the foundation for modern cardiovascular physiology. Since then, the analysis of the pressure-volume loops became a reference tool for the study of the ventricular pump properties. However, understanding cardiovascular performance requires both the evaluation of ventricular properties and the modulating effects of the arterial system, since the heart and the arterial tree are anatomically and functionally related structures. The study of the coupling between the cardiac function and the properties of the arterial system, or ventriculo-arterial (VA) coupling, provides then a comprehensive characterization of the performance of the cardiovascular system in both health and disease. The assessment of cardiovascular function is an essential element of the hemodynamic evaluation of critically ill patients. Both left and right ventricular dysfunction and arterial system disturbances are frequent in these patients. Since VA coupling ultimately defines de performance and efficiency of the cardiovascular system, the analysis of the interaction between the heart and the arterial system could offer a broader perspective of the hemodynamic disorders associated with common conditions, such as septic shock, heart failure, or right ventricular dysfunction. Moreover, this analysis could also provide valuable information about their pathophysiological mechanisms and may help to determine the best therapeutic strategy to correct them. In this review, we will describe the basic principles of the VA coupling assessment, its limitations, and the most common methods for its estimation at the bedside. Then, we will summarize the current knowledge of the application of VA coupling in critically ill patients and suggest some recommendations for further research.
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Affiliation(s)
| | - Arnoldo Santos
- Centro de Investigación Biomédica en Red (CIBER). Madrid, España.,ITC Ingeniería y Técnicas Clínicas SA, Madrid, España
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24
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Hsu S, Simpson CE, Houston BA, Wand A, Sato T, Kolb TM, Mathai SC, Kass DA, Hassoun PM, Damico RL, Tedford RJ. Multi-Beat Right Ventricular-Arterial Coupling Predicts Clinical Worsening in Pulmonary Arterial Hypertension. J Am Heart Assoc 2020; 9:e016031. [PMID: 32384024 PMCID: PMC7660856 DOI: 10.1161/jaha.119.016031] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/17/2020] [Indexed: 11/16/2022]
Abstract
Background Although right ventricular (RV) to pulmonary arterial (RV-PA) coupling is considered the gold standard in assessing RV dysfunction, its ability to predict clinically significant outcomes is poorly understood. We assessed the ability of RV-PA coupling, determined by the ratio of multi-beat (MB) end-systolic elastance (Ees) to effective arterial elastance (Ea), to predict clinical outcomes. Methods and Results Twenty-six subjects with pulmonary arterial hypertension (PAH) underwent same-day cardiac magnetic resonance imaging, right heart catheterization, and RV pressure-volume assessment with MB determination of Ees/Ea. RV ejection fraction (RVEF), stroke volume/end-systolic volume, and single beat-estimated Ees/Ea were also determined. Patients were treated with standard therapies and followed prospectively until they met criteria of clinical worsening (CW), as defined by ≥10% decline in 6-minute walk distance, worsening World Health Organization (WHO) functional class, PAH therapy escalation, RV failure hospitalization, or transplant/death. Subjects were 57±14 years, largely WHO class III (50%) at enrollment, with preserved average RV ejection fraction (RVEF) (47±11%). Mean follow-up was 3.2±1.3 years. Sixteen (62%) subjects met CW criteria. MB Ees/Ea was significantly lower in CW subjects (0.7±0.5 versus 1.3±0.8, P=0.02). The optimal MB Ees/Ea cut-point predictive of CW was 0.65, defined by ROC (AUC 0.78, P=0.01). MB Ees/Ea below this cut-point was significantly associated with time to CW (hazard ratio 5.1, P=0.001). MB Ees/Ea remained predictive of outcomes following multivariate adjustment for timing of PAH diagnosis and PAH diagnosis subtype. Conclusions RV-PA coupling as measured by MB Ees/Ea has prognostic significance in human PAH, even in a cohort with preserved RVEF.
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Affiliation(s)
- Steven Hsu
- Department of MedicineJohns Hopkins UniversityBaltimoreMD
| | | | - Brian A. Houston
- Department of MedicineMedical University of South CarolinaCharlestonSC
| | - Alison Wand
- Department of MedicineJohns Hopkins UniversityBaltimoreMD
| | - Takahiro Sato
- First Department of MedicineHokkaido University HospitalSapporoJapan
| | - Todd M. Kolb
- Department of MedicineJohns Hopkins UniversityBaltimoreMD
| | | | - David A. Kass
- Department of MedicineJohns Hopkins UniversityBaltimoreMD
| | | | | | - Ryan J. Tedford
- Department of MedicineMedical University of South CarolinaCharlestonSC
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25
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26
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Richter MJ, Peters D, Ghofrani HA, Naeije R, Roller F, Sommer N, Gall H, Grimminger F, Seeger W, Tello K. Evaluation and Prognostic Relevance of Right Ventricular-Arterial Coupling in Pulmonary Hypertension. Am J Respir Crit Care Med 2020; 201:116-119. [PMID: 31539478 DOI: 10.1164/rccm.201906-1195le] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Dana Peters
- Justus-Liebig-University GiessenGiessen, Germany
| | - Hossein A Ghofrani
- Justus-Liebig-University GiessenGiessen, Germany.,Rheuma and Thoracic CenterBad Nauheim, Germany.,Imperial College LondonLondon, United Kingdomand
| | | | - Fritz Roller
- Justus-Liebig-University GiessenGiessen, Germany
| | | | - Henning Gall
- Justus-Liebig-University GiessenGiessen, Germany
| | | | | | - Khodr Tello
- Justus-Liebig-University GiessenGiessen, Germany
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27
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Bellofiore A, Goss KN, Mulchrone A, Chesler NC. Reply to Tello et al.: Pending Right Heart Failure in Healthy Preterm-Born Subjects? Am J Respir Crit Care Med 2020; 201:1009-1010. [PMID: 31910032 PMCID: PMC7159418 DOI: 10.1164/rccm.201912-2356le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Kara N. Goss
- University of Wisconsin-MadisonMadison, Wisconsin
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28
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Kopf KW, Harral JW, Staker EA, Summers ME, Petrache I, Kheyfets V, Irwin DC, Majka SM. Optimization of combined measures of airway physiology and cardiovascular hemodynamics in mice. Pulm Circ 2020; 10:2045894020912937. [PMID: 32206308 PMCID: PMC7074541 DOI: 10.1177/2045894020912937] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 02/11/2020] [Indexed: 12/11/2022] Open
Abstract
Pulmonary hypertension may arise as a complication of chronic lung disease typically associated with tissue hypoxia, as well as infectious agents or injury eliciting a type 2 immune response. The onset of pulmonary hypertension in this setting (classified as Group 3) often complicates treatment and worsens prognosis of chronic lung disease. Chronic lung diseases such as chronic obstructive lung disease (COPD), emphysema, and interstitial lung fibrosis impair airflow and alter lung elastance in addition to affecting pulmonary vascular hemodynamics that may culminate in right ventricle dysfunction. To date, functional endpoints in murine models of chronic lung disease have typically been limited to separately measuring airway and lung parenchyma physiology. These approaches may be lengthy and require a large number of animals per experiment. Here, we provide a detailed protocol for combined assessment of airway physiology with cardiovascular hemodynamics in mice. Ultimately, a comprehensive overview of pulmonary function in murine models of injury and disease will facilitate the integration of studies of the airway and vascular biology necessary to understand underlying pathophysiology of Group 3 pulmonary hypertension.
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Affiliation(s)
- Katrina W Kopf
- Biological Resource Center, National Jewish Health, Denver, USA
| | - Julie W Harral
- Department of Medicine, Division of Pulmonary, Critical Care & Sleep Medicine, National Jewish Health, Denver, USA
| | - Emily A Staker
- Department of Medicine, Division of Pulmonary, Critical Care & Sleep Medicine, National Jewish Health, Denver, USA
| | - Megan E Summers
- Department of Medicine, Division of Pulmonary, Critical Care & Sleep Medicine, National Jewish Health, Denver, USA
| | - Irina Petrache
- Department of Medicine, Division of Pulmonary, Critical Care & Sleep Medicine, National Jewish Health, Denver, USA
| | - Vitaly Kheyfets
- Department of Bioengineering, Anschutz Medical Campus University of Colorado, Aurora, USA
| | - David C Irwin
- Department of Medicine, Division of Cardiology, Anschutz Medical Campus University of Colorado, Aurora, USA
| | - Susan M Majka
- Department of Medicine, Division of Pulmonary, Critical Care & Sleep Medicine, National Jewish Health, Denver, USA.,Department of Biomedical Research, National Jewish Health, Denver, USA.,Gates Center for Regenerative Medicine and Stem Cell Biology and Cardiology University of Colorado Medical Center, Aurora, USA
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29
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Heerdt PM, Kheyfets V, Charania S, Elassal A, Singh I. A pressure-based single beat method for estimation of right ventricular ejection fraction: proof of concept. Eur Respir J 2020; 55:13993003.01635-2019. [PMID: 31771999 DOI: 10.1183/13993003.01635-2019] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/13/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Paul M Heerdt
- Dept of Anesthesiology, Division of Applied Hemodynamics, Yale School of Medicine, New Haven, CT, USA
| | - Vitaly Kheyfets
- Dept of Bioengineering, School of Medicine, University of Colorado Denver, Anschutz Medical Center, Aurora, CO, USA
| | - Sofia Charania
- Dept of Anesthesiology, Division of Applied Hemodynamics, Yale School of Medicine, New Haven, CT, USA
| | - Ahmed Elassal
- Dept of Anesthesiology, Division of Applied Hemodynamics, Yale School of Medicine, New Haven, CT, USA
| | - Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Dept of Medicine, Yale School of Medicine, New Haven, CT, USA
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30
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Naeije R, Richter MJ, Vanderpool R, Tello K. When it all comes down to pressure: right ventricular ejection fraction at cardiac catheterisation. Eur Respir J 2020; 55:55/3/1902341. [DOI: 10.1183/13993003.02341-2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 12/10/2019] [Indexed: 01/29/2023]
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31
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Mulchrone A, Bellofiore A, Douwes JM, Duong N, Beshish AG, Barton GP, Francois CJ, Eldridge MW, Goss KN, Chesler NC. Impaired Right Ventricular-Vascular Coupling in Young Adults Born Preterm. Am J Respir Crit Care Med 2020; 201:615-618. [PMID: 31697579 PMCID: PMC7047464 DOI: 10.1164/rccm.201904-0767le] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | - Neal Duong
- University of Wisconsin–MadisonMadison, Wisconsin
| | | | | | | | | | - Kara N. Goss
- University of Wisconsin–MadisonMadison, Wisconsin
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32
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Vanderpool RR, Puri R, Osorio A, Wickstrom K, Desai AA, Black SM, Garcia JG, Yuan JXJ, Rischard FP. EXPRESS: Surfing the Right Ventricular Pressure Waveform: Methods to assess Global, Systolic and Diastolic RV Function from a Clinical Right Heart Catheterization. Pulm Circ 2019; 10:2045894019850993. [PMID: 31032737 PMCID: PMC7031797 DOI: 10.1177/2045894019850993] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 04/01/2019] [Indexed: 12/12/2022] Open
Abstract
Right ventricular (RV) function strongly associates with mortality in patients with pulmonary arterial hypertension (PAH). Current methods to determine RV function require temporal measurements of pressure and volume. The aim of the study was to investigate the feasibility of using right heart catheterization (RHC) measurements to estimate systolic and diastolic RV function. RV pressure and volume points were fit to P = α(eβV-1) to assess diastolic stiffness coefficient (β) and end-diastolic elastance (Eed). Single-beat methods were used to assess RV contractility (Ees). The effects of a non-zero unstressed RV volume (V0), RHC-derived stroke volume (SVRHC), and normalization of the end-diastolic volume (EDV) on estimates of β, Eed, and Ees were tested using Bland–Altman analysis in an incident PAH cohort (n = 32) that had both a RHC and cardiac magnetic resonance (CMR) test. RHC-derived measures of RV function were used to detect the effect of prostacyclin therapy in an incident PAH cohort and the severity of PAH in prevalent PAH (n = 21). A non-zero V0 had a minimal effect on β with a small bias and limits of agreement (LOA). Stroke volume (SV) significantly influenced estimates of β and Ees with a large LOA. Normalization of EDV had minimal effect on both β and Eed. RHC-derived β and Eed increased due to the severity of PAH and decreased due to three months of prostacyclin therapy. It is feasible to detect therapeutic changes in specific stiffness and elastic properties of the RV from signal-beat pressure-volume loops by using RHC-derived SV and normalizing RV EDV.
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Affiliation(s)
- Rebecca R. Vanderpool
- Division of Translational and Regenerative Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Reena Puri
- Division of Translational and Regenerative Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Alexandra Osorio
- Division of Translational and Regenerative Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Kelly Wickstrom
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Ankit A. Desai
- Division of Translational and Regenerative Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
- Division of Cardiology, Department of Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
- Department of Medicine, Indiana University, Indianapolis, IN, USA
| | - Stephen M. Black
- Division of Translational and Regenerative Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
- Department of Physiology, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Joe G.N. Garcia
- Division of Translational and Regenerative Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
- Department of Physiology, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Jason X.-J. Yuan
- Division of Translational and Regenerative Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
- Department of Physiology, The University of Arizona College of Medicine, Tucson, AZ, USA
- Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Franz P. Rischard
- Division of Translational and Regenerative Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
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