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Culp C, Andrews J, Sun KW, Hunter K, Cherry A, Podgoreanu M, Nicoara A. Right Ventricle-Pulmonary Artery Coupling in Patients Undergoing Cardiac Interventions. Curr Cardiol Rep 2024; 26:521-537. [PMID: 38581563 DOI: 10.1007/s11886-024-02052-3] [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] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE OF REVIEW This review aims to summarize the fundamentals of RV-PA coupling, its non-invasive means of measurement, and contemporary understanding of RV-PA coupling in cardiac surgery, cardiac interventions, and congenital heart disease. RECENT FINDINGS The need for more accessible clinical means of evaluation of RV-PA coupling has driven researchers to investigate surrogates using cardiac MRI, echocardiography, and right-sided pressure measurements in patients undergoing cardiac surgery/interventions, as well as patients with congenital heart disease. Recent research has aimed to validate these alternative means against the gold standard, as well as establish cut-off values predictive of morbidity and/or mortality. This emerging evidence lays the groundwork for identifying appropriate RV-PA coupling surrogates and integrating them into perioperative clinical practice.
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Affiliation(s)
- Crosby Culp
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA.
| | - Jon Andrews
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
| | - Katherine Wang Sun
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
| | - Kendall Hunter
- Department of Bioengineering, University of Colorado, Aurora, CO, USA
| | - Anne Cherry
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
| | - Mihai Podgoreanu
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
| | - Alina Nicoara
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
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Andersen S, Laursen PH, Wood GJ, Lyhne MD, Madsen TL, Hansen ESS, Johansen P, Kim WY, Andersen MJ. Comparison of admittance and cardiac magnetic resonance generated pressure-volume loops in a porcine model. Physiol Meas 2024; 45:055014. [PMID: 38729184 DOI: 10.1088/1361-6579/ad4a03] [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: 02/21/2024] [Accepted: 05/10/2024] [Indexed: 05/12/2024]
Abstract
Objective. Pressure-volume loop analysis, traditionally performed by invasive pressure and volume measurements, is the optimal method for assessing ventricular function, while cardiac magnetic resonance (CMR) imaging is the gold standard for ventricular volume estimation. The aim of this study was to investigate the agreement between the assessment of end-systolic elastance (Ees) assessed with combined CMR and simultaneous pressure catheter measurements compared with admittance catheters in a porcine model.Approach. Seven healthy pigs underwent admittance-based pressure-volume loop evaluation followed by a second assessment with CMR during simultaneous pressure measurements.Main results. Admittance overestimated end-diastolic volume for both the left ventricle (LV) and the right ventricle (RV) compared with CMR. Further, there was an underestimation of RV end-systolic volume with admittance. For the RV, however, Ees was systematically higher when assessed with CMR plus simultaneous pressure measurements compared with admittance whereas there was no systematic difference in Ees but large differences between admittance and CMR-based methods for the LV.Significance. LV and RV Ees can be obtained from both admittance and CMR based techniques. There were discrepancies in volume estimates between admittance and CMR based methods, especially for the RV. RV Ees was higher when estimated by CMR with simultaneous pressure measurements compared with admittance.
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Affiliation(s)
- Stine Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Pernille Holmberg Laursen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Gregory John Wood
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mads Dam Lyhne
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Tobias Lynge Madsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, MR research Centre, Aarhus University, Aarhus, Denmark
| | | | - Peter Johansen
- Department of Electrical and Computer Engineering, Aarhus University, Aarhus, Denmark
| | - Won Yong Kim
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mads Jønsson Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Palmiero P, Caretto P, Zito A, Ciccone MM, Pelliccia F, Maiello M. Left ventricular diastolic function in atrial fibrillation: Methodological implications and clinical considerations. Echocardiography 2024; 41:e15818. [PMID: 38654654 DOI: 10.1111/echo.15818] [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: 02/12/2024] [Revised: 04/06/2024] [Accepted: 04/08/2024] [Indexed: 04/26/2024] Open
Abstract
The assessment of LVDD is routinely included in echocardiographic evaluation because it correlates with cardiac disease progression and its prognostic value. Classic parameters used for assessing LV diastolic function correlate well with invasive measurements which remains the gold standard. Nevertheless, no one echocardiographic parameter alone can completely evaluate LVDD. LV diastolic function evaluation in atrial fibrillation is still challenging, since the E/A ratio, one of the most used parameters in echocardiographic evaluation, cannot be feasible. This is not a good reason to give up measurement. In this review, we analyze the different methods for estimating LV diastolic function in atrial fibrillation, including measurement not dependent on atrial systole and some novel methods that are promising, but not ever available during clinical practice highlighting that this assessment is mandatory for a complete clinical evaluation of the patients.
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Affiliation(s)
- Pasquale Palmiero
- ASL Brindisi, Cardiology Equipe, District of Brindisi, Brindisi, Italy
- Medical School, University of Bari, Bari, Italy
| | - Pierpaolo Caretto
- University Cardiology Unit, Interdisciplinary Department of Medicine, Polyclinic University Hospital, Bari, Italy
| | - Annapaola Zito
- ASL Brindisi, District of Francavilla Fontana, Brindisi, Italy
| | - Marco Matteo Ciccone
- University Cardiology Unit, Interdisciplinary Department of Medicine, Polyclinic University Hospital, Bari, Italy
| | | | - Maria Maiello
- ASL Brindisi, Cardiology Equipe, District of Brindisi, Brindisi, Italy
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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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Matsushita H, Saku K, Nishikawa T, Yokota S, Sato K, Morita H, Yoshida Y, Fukumitsu M, Uemura K, Kawada T, Yamaura K. The impact of ECPELLA on haemodynamics and global oxygen delivery: a comprehensive simulation of biventricular failure. Intensive Care Med Exp 2024; 12:13. [PMID: 38361021 PMCID: PMC10869331 DOI: 10.1186/s40635-024-00599-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/18/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND ECPELLA, a combination of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) and Impella, a percutaneous left ventricular (LV) assist device, has emerged as a novel therapeutic option in patients with severe cardiogenic shock (CS). Since multiple cardiovascular and pump factors influence the haemodynamic effects of ECPELLA, optimising ECPELLA management remains challenging. In this study, we conducted a comprehensive simulation study of ECPELLA haemodynamics. We also simulated global oxygen delivery (DO2) under ECPELLA in severe CS and acute respiratory failure as a first step to incorporate global DO2 into our developed cardiovascular simulation. METHODS AND RESULTS Both the systemic and pulmonary circulations were modelled using a 5-element resistance‒capacitance network. The four ventricles were represented by time-varying elastances with unidirectional valves. In the scenarios of severe LV dysfunction, biventricular dysfunction with normal pulmonary vascular resistance (PVR, 0.8 Wood units), and biventricular dysfunction with high PVR (6.0 Wood units), we compared the changes in haemodynamics, pressure-volume relationship (PV loop), and global DO2 under different VA-ECMO flows and Impella support levels. RESULTS In the simulation, ECPELLA improved total systemic flow with a minimising biventricular pressure-volume loop, indicating biventricular unloading in normal PVR conditions. Meanwhile, increased Impella support level in high PVR conditions rendered the LV-PV loop smaller and induced LV suction in ECPELLA support conditions. The general trend of global DO2 was followed by the changes in total systemic flow. The addition of veno-venous ECMO (VV-ECMO) augmented the global DO2 increment under ECPELLA total support conditions. CONCLUSIONS The optimal ECPELLA support increased total systemic flow and achieved both biventricular unloading. The VV-ECMO effectively improves global DO2 in total ECPELLA support conditions.
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Affiliation(s)
- Hiroki Matsushita
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.
| | - Takuya Nishikawa
- Department of Research Promotion and Management, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Shohei Yokota
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kei Sato
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Hidetaka Morita
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Yuki Yoshida
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Masafumi Fukumitsu
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kazunori Uemura
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
- NTTR-NCVC Bio Digital Twin Centre, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Nguyen R, Murra A, Capdeville M. Chronic Thromboembolic Pulmonary Hypertension Due to a Rare Anterior Mediastinal Venous Malformation. J Cardiothorac Vasc Anesth 2024; 38:552-557. [PMID: 36528502 DOI: 10.1053/j.jvca.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/16/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Rachel Nguyen
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH
| | - Ali Murra
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH
| | - Michelle Capdeville
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH.
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Edward JA, Parker H, Stöhr EJ, McDonnell BJ, O'Gean K, Schulte M, Lawley JS, Cornwell WK. Exertional Cardiac and Pulmonary Vascular Hemodynamics in Patients With Heart Failure With Reduced Ejection Fraction. J Card Fail 2023; 29:1276-1284. [PMID: 36871613 PMCID: PMC10477310 DOI: 10.1016/j.cardfail.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Exertional dyspnea is a cardinal manifestation of heart failure with reduced ejection fraction (HFrEF), but quantitative data regarding exertional hemodynamics are lacking. OBJECTIVES We sought to characterize exertional cardiopulmonary hemodynamics in patients with HFrEF. METHODS We studied 35 patients with HFrEF (59 ± 12 years old, 30 males) who completed invasive cardiopulmonary exercise testing. Data were collected at rest, at submaximal exercise and at peak effort on upright cycle ergometry. Cardiovascular and pulmonary vascular hemodynamics were recorded. Fick cardiac output (Qc) was determined. Hemodynamic predictors of peak oxygen uptake (VO2) were identified. RESULTS Left ventricular ejection fraction and cardiac index were 23% ± 8% and 2.9 ± 1.1 L/min/m2, respectively. Peak VO2 was 11.8 ± 3.3 mL/kg/min, and the ventilatory efficiency slope was 53 ± 13. Right atrial pressure increased from rest to peak exercise (4 ± 5 vs 7 ± 6 mmHg,). Mean pulmonary arterial pressure increased from rest to peak exercise (27 ± 13 vs 38 ± 14 mmHg). Pulmonary artery pulsatility index increased from rest to peak exercise, while pulmonary arterial capacitance and pulmonary vascular resistance declined. CONCLUSIONS Patients with HFrEF suffer from marked increases in filling pressures during exercise. These findings provide new insight into cardiopulmonary abnormalities contributing to impairments in exercise capacity in this population. CLINICAL TRIAL REGISTRATION clinicaltrials.gov identifier: NCT03078972.
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Affiliation(s)
- Justin A Edward
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Hugh Parker
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Eric J Stöhr
- Leibniz University Hannover, COR-HELIX (Cardiovascular Regulation and Human Exercise Laboratory-Integration and Xploration), Hannover, Germany; Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York NY, USA
| | - Barry J McDonnell
- Cardiovascular Physiology Research Group, Cardiff School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom
| | - Katie O'Gean
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Margaret Schulte
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Justin S Lawley
- University of Innsbruck, Department of Sport Science, Innsbruck, Austria
| | - William K Cornwell
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO; Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, CO.
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Reddy SA, Swietlik EM, Robertson L, Michael A, Boyle S, Polwarth G, Screaton NJ, Ruggiero A, Nethercott SL, Taboada D, Sheares KK, Hadinnapola C, Cannon JE, Bunclark K, Jenkins D, Ng C, Toshner MR, Pepke-Zaba J. Natural history of chronic thromboembolic pulmonary disease with no or mild pulmonary hypertension. J Heart Lung Transplant 2023; 42:1275-1285. [PMID: 37201688 DOI: 10.1016/j.healun.2023.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 03/31/2023] [Accepted: 04/27/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND We describe baseline characteristics, disease progression and mortality in chronic thromboembolic pulmonary disease patients as a function of mean pulmonary artery pressure (mPAP) according to new and previous definitions of pulmonary hypertension. METHODS All patients diagnosed with chronic thromboembolic pulmonary disease between January, 2015 and December, 2019 were dichotomized according to initial mPAP: ≤ 20 mmHg ('normal') vs 21-24 mmHg ('mildly-elevated'). Baseline features were compared between the groups, and pairwise analysis performed to determine changes in clinical endpoints at 1-year, excluding those who underwent pulmonary endarterectomy or did not attend follow-up. Mortality was assessed for the whole cohort over the entire study period. RESULTS One hundred thirteen patients were included; 57 had mPAP ≤ 20 mmHg and 56 had mPAP 21-24 mmHg. Normal mPAP patients had lower pulmonary vascular resistance (1.6 vs 2.5WU, p < 0.01) and right ventricular end-diastolic pressure (5.9 vs 7.8 mmHg, p < 0.01) at presentation. At 3 years, no major deterioration was seen in either group. No patients were treated with pulmonary artery vasodilators. Eight had undergone pulmonary endarterectomy. Over 37 months median follow-up, mortality was 7.0% in the normal mPAP group and 8.9% in the mildly-elevated mPAP group. Cause of death was malignancy in 62.5% of cases. CONCLUSIONS Chronic thromboembolic pulmonary disease patients with mild pulmonary hypertension have statistically higher right ventricular end-diastolic pressure and pulmonary vascular resistance than those with mPAP ≤ 20 mmHg. Baseline characteristics were otherwise similar. Neither group displayed disease progression on non-invasive tests up to 3 years. Mortality over 37 months follow-up is 8%, and mainly attributable to malignancy. Further prospective study is required to validate these findings.
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Affiliation(s)
- Sathineni A Reddy
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK.
| | - Emilia M Swietlik
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Lucy Robertson
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Alice Michael
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Sonja Boyle
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Gary Polwarth
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Nick J Screaton
- Department of Radiology, Royal Papworth Hospital, Cambridge, UK
| | | | | | - Dolores Taboada
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Karen K Sheares
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - John E Cannon
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - David Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Choo Ng
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Mark R Toshner
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK; Addenbrookes Hospital, Cambridge, UK
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
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Tello K, Naeije R, de Man F, Guazzi M. Pathophysiology of the right ventricle in health and disease: an update. Cardiovasc Res 2023; 119:1891-1904. [PMID: 37463510 DOI: 10.1093/cvr/cvad108] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/14/2023] [Accepted: 05/02/2023] [Indexed: 07/20/2023] Open
Abstract
The contribution of the right ventricle (RV) to cardiac output is negligible in normal resting conditions when pressures in the pulmonary circulation are low. However, the RV becomes relevant in healthy subjects during exercise and definitely so in patients with increased pulmonary artery pressures both at rest and during exercise. The adaptation of RV function to loading rests basically on an increased contractility. This is assessed by RV end-systolic elastance (Ees) to match afterload assessed by arterial elastance (Ea). The system has reserve as the Ees/Ea ratio or its imaging surrogate ejection fraction has to decrease by more than half, before the RV undergoes an increase in dimensions with eventual increase in filling pressures and systemic congestion. RV-arterial uncoupling is accompanied by an increase in diastolic elastance. Measurements of RV systolic function but also of diastolic function predict outcome in any cause pulmonary hypertension and heart failure with or without preserved left ventricular ejection fraction. Pathobiological changes in the overloaded RV include a combination of myocardial fibre hypertrophy, fibrosis and capillary rarefaction, a titin phosphorylation-related displacement of myofibril tension-length relationships to higher pressures, a metabolic shift from mitochondrial free fatty acid oxidation to cytoplasmic glycolysis, toxic lipid accumulation, and activation of apoptotic and inflammatory signalling pathways. Treatment of RV failure rests on the relief of excessive loading.
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Affiliation(s)
- Khodr Tello
- Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Klinikstrasse 36, 35392 Giessen, Germany
| | - Robert Naeije
- Pathophysiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium
| | - Frances de Man
- Pulmonary Medicine, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Marco Guazzi
- Cardiology Division, San Paolo University Hospital, University of Milano, Milano, Italy
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Samaranayake CB, Upham J, Tran K, Howard LS, Nguyen S, Lwin M, Anderson J, Wahi S, Price LC, Wort S, Li W, McCabe C, Keir GJ. Right ventricular functional recovery assessment with stress echocardiography and cardiopulmonary exercise testing after pulmonary embolism: a pilot prospective multicentre study. BMJ Open Respir Res 2023; 10:e001637. [PMID: 37491130 PMCID: PMC10373684 DOI: 10.1136/bmjresp-2023-001637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/30/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Data on right ventricular (RV) exercise adaptation following acute intermediate and high-risk pulmonary embolism (PE) remain limited. This study aimed to evaluate the symptom burden, RV functional recovery during exercise and cardiopulmonary exercise parameters in survivors of intermediate and high-risk acute PE. METHODS We prospectively recruited patients following acute intermediate and high-risk PE at four sites in Australia and UK. Study assessments included stress echocardiography, cardiopulmonary exercise testing (CPET) and ventilation-perfusion (VQ) scan at 3 months follow-up. RESULTS Thirty patients were recruited and 24 (median age: 55 years, IQR: 22) completed follow-up. Reduced peak oxygen consumption (VO2) and workload was seen in 75.0% (n=18), with a persistent high symptom burden (mean PEmb-QoL Questionnaire 48.4±21.5 and emPHasis-10 score 22.4±8.8) reported at follow-up. All had improvement in RV-focused resting echocardiographic parameters. RV systolic dysfunction and RV to pulmonary artery (PA) uncoupling assessed by stress echocardiography was seen in 29.2% (n=7) patients and associated with increased ventilatory inefficiency (V̇E/V̇CO2 slope 47.6 vs 32.4, p=0.03), peak exercise oxygen desaturation (93.2% vs 98.4%, p=0.01) and reduced peak oxygen pulse (p=0.036) compared with controls. Five out of seven patients with RV-PA uncoupling demonstrated persistent bilateral perfusion defects on VQ scintigraphy consistent with chronic thromboembolic pulmonary vascular disease. CONCLUSION In our cohort, impaired RV adaptation on exercise was seen in almost one-third of patients. Combined stress echocardiography and CPET may enable more accurate phenotyping of patients with persistent symptoms following acute PE to allow timely detection of long-term complications.
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Affiliation(s)
- Chinthaka Bhagya Samaranayake
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - John Upham
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Khoa Tran
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Respiratory Medicine, Logan Hospital, Loganholme, Queensland, Australia
| | - Luke S Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Sean Nguyen
- Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Myo Lwin
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK
| | - James Anderson
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Sudhir Wahi
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Laura C Price
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Stephen Wort
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Wei Li
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Colm McCabe
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Gregory J Keir
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
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Hadinnapola CM, Southwood M, Hernández-Sánchez J, Bunclark K, Newnham M, Swietlik EM, Cannon J, Preston SD, Sheares K, Taboada D, Screaton N, Jenkins DP, Morrell NW, Toshner M, Pepke-Zaba J. Angiopoietin 2 and hsCRP are associated with pulmonary hemodynamics and long-term mortality respectively in CTEPH-Results from a prospective discovery and validation biomarker study. J Heart Lung Transplant 2023; 42:398-405. [PMID: 36609091 DOI: 10.1016/j.healun.2022.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 08/17/2022] [Accepted: 08/27/2022] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed disease of uncertain etiology. Altered endothelial homeostasis, defective angiogenesis and inflammation are implicated. Angiopoietin 2 (Ang2) impairs acute thrombus resolution and is associated with vasculopathy in idiopathic pulmonary arterial hypertension. METHODS We assessed circulating proteins associated with these processes in serum from patients with CTEPH (n = 71) before and after pulmonary endarterectomy (PEA), chronic thromboembolic pulmonary disease without pulmonary hypertension (CTEPD, n = 9) and healthy controls (n = 20) using Luminex multiplex arrays. Comparisons between groups were made using multivariable rank regression models. Ang2 and high-sensitivity C-reactive protein (hsCRP) were measured in a larger validation dataset (CTEPH = 277, CTEPD = 26). Cox proportional hazards models were used to identify markers predictive of survival. RESULTS In CTEPH patients, Ang2, interleukin (IL) 8, tumor necrosis factor α, and hsCRP were elevated compared to controls, while vascular endothelial growth factor (VEGF) c was lower (p < 0.05). Ang2 fell post-PEA (p < 0.05) and was associated with both pre- and post-PEA pulmonary hemodynamic variables and functional assessments (p < 0.05). In the validation dataset, Ang2 was significantly higher in CTEPH compared to CTEPD. Pre-operative hsCRP was an independent predictor of mortality. CONCLUSIONS We hypothesize that CTEPH patients have significant distal micro-vasculopathy and consequently high circulating Ang2. Patients with CTEPD without pulmonary hypertension have no discernible distal micro-vasculopathy and therefore have low circulating Ang2. This suggests Ang2 may be critical to CTEPH disease pathogenesis (impaired thrombus organization and disease severity).
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Affiliation(s)
- Charaka M Hadinnapola
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK; Norfolk and Norwich University Hospital, University of East Anglia, Colney Lane, Norwich, UK
| | - Mark Southwood
- Department of Histopathology, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK
| | - Jules Hernández-Sánchez
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK; MRC Biostatistics Unit, Cambridge Institute of Public Health, Cambridge Biomedical Campus, Cambridge, UK
| | - Katherine Bunclark
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK; Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - Michael Newnham
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK; Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK; Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Emilia M Swietlik
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK; Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - John Cannon
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK
| | - Stephen D Preston
- Department of Histopathology, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK
| | - Karen Sheares
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK
| | - Dolores Taboada
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK
| | - Nicholas Screaton
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK
| | - David P Jenkins
- Department of Surgery, Royal Papworth Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - Nicholas W Morrell
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - Mark Toshner
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK.
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12
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Aslanger E, Akaslan D, Ataş H, Kocakaya D, Yıldızeli B, Mutlu B. Right Ventricular Energy Failure Predicts Mortality in Patients With Pulmonary Hypertension. Am J Cardiol 2023; 193:19-27. [PMID: 36857840 DOI: 10.1016/j.amjcard.2023.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/08/2023] [Accepted: 01/30/2023] [Indexed: 03/03/2023]
Abstract
Right ventricular (RV) failure has a significant adverse impact on pulmonary hypertension (PH) prognosis. None of the currently used parameters directly assess whether RV fails to provide enough energy output to propel the blood through diseased pulmonary vascular system. Furthermore, most of the current parameters are affected by the volume status of the patient. We aimed to explore whether RV energy failure has a predictive power for mortality on top of the established prognostic risk parameters in patients with PH. We screened 723 cases from our database. A total of 3 sets of binary regression analyses were executed to determine the hazard ratios (HRs) of RV energy failure for 5-year mortality in clinical, echocardiographic, and hemodynamic context, using adjustment variables chosen according to previous studies. The final study population encompassed 549 cases. A total of 77 patients died during the 5-year follow-up (14%). RV energy failure was observed in 146 of 549 patients (26.6%). In the univariate model, RV energy failure strongly associated with increased long-term mortality (HR 4.25, 95% confidence interval [CI] 2.58 to 7.00, p <0.001). It also emerged as a significant predictor of long-term mortality in clinical and hemodynamic multivariate models (HR 2.59, 95% CI 1.43 to 4.67, p = 0.002 and HR 2.05, 95% CI 1.15 to 3.63, p = 0.015, respectively). In conclusion, our study indicates that the presence of RV energy failure independently predicts long-term mortality in PH.
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Affiliation(s)
- Emre Aslanger
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey.
| | - Dursun Akaslan
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
| | - Halil Ataş
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
| | | | - Bedrettin Yıldızeli
- Thoracic Surgery, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
| | - Bülent Mutlu
- Department of Cardiology, Pendik Training and Research Hospital, Marmara University, Istanbul, Turkey
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13
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Bartnik A, Pepke-Zaba J, Hoole SP, White P, Garbi M, Coghlan JG, Taghavi F, Tsui S, Weir-McCall J. Right ventricular-pulmonary artery coupling in chronic thromboembolic pulmonary hypertension. Heart 2022; 109:898-904. [PMID: 36549680 DOI: 10.1136/heartjnl-2022-321770] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension occurs in a proportion of patients with prior acute pulmonary embolism and is characterised by breathlessness, persistently raised pulmonary pressures and right heart failure. Surgical pulmonary endarterectomy (PEA) offers significant prognostic and symptomatic benefits for patients with proximal disease distribution. For those with inoperable disease, management options include balloon pulmonary angioplasty (BPA) and medical therapy. Current clinical practice relies on the evaluation of pulmonary haemodynamics to assess disease severity, timing of and response to treatment. However, pulmonary haemodynamics correlate poorly with patient symptoms, which are influenced by right ventricular tolerance of the increased afterload. How best to manage symptomatic patients with chronic thromboembolic pulmonary disease (CTEPD) in the absence of pulmonary hypertension is not resolved.Right ventricular-pulmonary artery coupling (RV-PAC) describes the energy transfer within the whole cardiopulmonary unit. Thus, it can identify the earliest signs of decompensation even before pulmonary hypertension is overt. Invasive measurement of coupling using pressure volume loop technology is well established in research settings. The development of efficient and less invasive measurement methods has revived interest in coupling as a viable clinical tool. Significant improvement in RV-PAC has been demonstrated after both PEA and BPA. Further studies are required to understand its clinical utility and prognostic value, in particular, its potential to guide management in patients with CTEPD. Finally, given the reported differences in coupling between sexes in pulmonary arterial hypertension, further work is required to understand the applicability of proposed thresholds for decoupling in therapeutic decision making.
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Affiliation(s)
- Aleksandra Bartnik
- Radiology, Royal Papworth Hospital, Cambridge, UK .,University of Cambridge, Cambridge, UK.,Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Paul White
- Medical Physics and Clinical Engineering, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Medical Technology Research Centre, Anglia Ruskin University, Cambridge, UK
| | | | | | | | - Steven Tsui
- Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Jonathan Weir-McCall
- Radiology, Royal Papworth Hospital, Cambridge, UK.,University of Cambridge, Cambridge, UK
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14
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Douschan P, Tello K, Rieth AJ, Wiedenroth CB, Sassmann T, Kovacs G, Ghofrani HA, Seeger W, Richter M, Guth S. Right ventricular-pulmonary arterial coupling and its relationship to exercise haemodynamics in a continuum of patients with pulmonary vascular disease due to chronic thromboembolism. Eur Respir J 2022; 60:13993003.00450-2022. [PMID: 35953102 DOI: 10.1183/13993003.00450-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/22/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Philipp Douschan
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig-University, Giessen, Germany.,Department of Internal Medicine, Division of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,These two authors contributed equally to this article
| | - Khodr Tello
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig-University, Giessen, Germany.,These two authors contributed equally to this article
| | - Andreas J Rieth
- Department of Cardiology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Teresa Sassmann
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Gabor Kovacs
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Hossein A Ghofrani
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig-University, Giessen, Germany.,Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,Department of Medicine, Imperial College London, London, UK
| | - Werner Seeger
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig-University, Giessen, Germany
| | - Manuel Richter
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig-University, Giessen, Germany.,These two authors contributed equally to this article
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany .,These two authors contributed equally to this article
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15
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed, but potentially curable pulmonary vascular disease. The increased pulmonary vascular resistance in CTEPH is caused by unresolved proximal thrombus and secondary microvasculopathy in the pulmonary vasculature, leading to adaptive and maladaptive remodeling of the right ventricle (RV), eventual right heart failure, and death. Knowledge on the RV remodeling process in CTEPH is limited. The progression to RV failure in CTEPH is a markedly slower process. A detailed understanding of the pathophysiology and underlying mechanisms of RV remodeling may facilitate early diagnosis and the development of targeted therapy. While ultrasound, magnetic resonance imaging, right heart catheterization, and serum biomarkers have been used to assess cardiac function, the current treatment strategies reduce the afterload of the right heart, but are less effective in improving the maladaptive remodeling of the right heart. This review systematically summarizes the current knowledge on adaptive and maladaptive remodeling of the right heart in CTEPH from molecular mechanisms to clinical practice.
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16
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Duan A, Li X, Jin Q, Zhang Y, Zhao Z, Zhao Q, Yan L, Huang Z, Hu M, Liu J, An C, Ma X, Xiong C, Luo Q, Liu Z. Prognostic implication of noninvasive right ventricle-to-pulmonary artery coupling in chronic thromboembolic pulmonary hypertension. Ther Adv Chronic Dis 2022; 13:20406223221102803. [PMID: 35757779 PMCID: PMC9218458 DOI: 10.1177/20406223221102803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/28/2022] [Indexed: 11/17/2022] Open
Abstract
Aims: Impairment of right ventricle-to-pulmonary artery coupling (RV-PA coupling) is a major determinant of poor prognosis in patients with pulmonary hypertension. This study sought to evaluate the ability of an echo-derived metric of RV-PA coupling, the ratio between tricuspid annular plane systolic excursion (TAPSE), and pulmonary artery systolic pressure (PASP) and to predict adverse clinical outcomes in chronic thromboembolic pulmonary hypertension (CTEPH). Methods and results: A total of 205 consecutive patients with confirmed CTEPH were retrospectively recruited from Fuwai Hospital between February 2016 and November 2020. Baseline echocardiography, right heart catheterization, and cardiopulmonary exercise testing were analyzed. Patients with lower TAPSE/PASP had a significantly compromised echocardiographic and hemodynamic status and exercise capacity at baseline. The TAPSE/PASP ratio correlated significantly with hemodynamic parameters, including pulmonary vascular resistance (r = −0.48, p < 0.001) and pulmonary arterial compliance (r = 0.45, p < 0.001). During a median period of 1-year follow-up, 63 (30.7%) patients experienced clinical worsening. The relationship between TAPSE/PASP and clinical worsening was assessed using different multivariate Cox regression models. After adjustment for a series of previously screened independent predictors, TAPSE/PASP remained significantly associated with outcomes, and the hazard ratio (per standard deviation increase) of the final model was 0.402. Conclusion: In patients with CTEPH, baseline RV-PA coupling measured as the TAPSE/PASP ratio is associated with disease severity and adverse outcomes. A low TAPSE/PASP identifies patients with a high risk of clinical deterioration, and this novel metric could be applicable for risk stratification in CTEPH.
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Affiliation(s)
- Anqi Duan
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xin Li
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qi Jin
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi Zhang
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhihui Zhao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qing Zhao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lu Yan
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhihua Huang
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Meixi Hu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jiaran Liu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Chenhong An
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiuping Ma
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Changming Xiong
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 Beilishi Rd, Xicheng District, Beijing 100037, China
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 Beilishi Rd, Xicheng District, Beijing 100037, China
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17
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Kremer N, Rako Z, Douschan P, Gall H, Ghofrani HA, Grimminger F, Guth S, Naeije R, Rieth A, Schulz R, Seeger W, Tedford RJ, Vadász I, Vanderpool R, Wiedenroth CB, Richter MJ, Tello K. Unmasking right ventricular-arterial uncoupling during fluid challenge in pulmonary hypertension. J Heart Lung Transplant 2021; 41:345-355. [PMID: 34972609 DOI: 10.1016/j.healun.2021.11.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/20/2021] [Accepted: 11/30/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Patients with pulmonary hypertension (PH) frequently show preserved right ventricular (RV) function at rest. However, volume challenge may uncover pending RV dysfunction. We aimed to assess the physiological and prognostic impact of RV-pulmonary arterial (RV-PA) uncoupling during volume challenge in patients with precapillary PH. METHODS We prospectively assessed 32 patients with PH (pulmonary arterial hypertension, n = 27; inoperable chronic thromboembolic disease, n = 5) and 4 controls using invasive pressure-volume (PV) catheterization. PV loops were recorded during preload reduction (balloon occlusion of inferior vena cava; baseline) and acute volume loading (200 ml saline in 20 s). Contractility (multi-beat end-systolic elastance [Ees]), arterial elastance (Ea), and RV-PA coupling (Ees/Ea) were obtained at baseline and at maximum volume loading (MVL). RESULTS Median [interquartile range] time to MVL was 19 [18-22] s. Ees/Ea significantly declined from baseline (0.89 [0.69-1.23]) to MVL (0.16 [0.12-0.34]; p < 0.001) in patients with PH but remained stable in controls (baseline: 1.08 [0.94-1.80]; MVL: 1.01 [0.80-2.49]; p = 0.715). The same pattern was observed for Ees, while Ea remained unchanged. The percent decline of RV-PA coupling (ΔEes/Ea) during fluid challenge was significantly associated with pulmonary resting hemodynamics, RV ejection fraction (RVEF), and RV end-diastolic volume. Kaplan-Meier analysis revealed that patients with PH who had a smaller ΔEes/Ea (<-65%) had a significantly better prognosis (log-rank p = 0.0389). In multivariate Cox regression analysis, clinical worsening was predicted by ΔEes/Ea (hazard ratio: 0.96 [95% confidence interval: 0.93-1.00]) and RVEF (hazard ratio: 0.95 [95% confidence interval: 0.92-0.98]). CONCLUSIONS Assessment of PV loops during fluid challenge uncovers exhausted RV coupling reserve with severely reduced contractility in PH. RV-PA uncoupling during volume challenge can be predicted by pulmonary resting hemodynamics and RVEF. RV-PA uncoupling during fluid challenge and RVEF (as a noninvasive correlate) are predictors of clinical worsening. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT03403868 (January 19, 2018).
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Affiliation(s)
- Nils Kremer
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Zvonimir Rako
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Philipp Douschan
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany; Division of Pulmonology, Department of Internal Medicine and Ludwig Boltzmann Institute for Lung Vascular Research, Medical University of Graz, Graz, Austria
| | - Henning Gall
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Hossein A Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany; Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany; Department of Medicine, Imperial College London, London, UK
| | - Friedrich Grimminger
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany; Institute for Lung Health, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | | | - Andreas Rieth
- Department of Cardiology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Rainer Schulz
- Institute of Physiology, Justus-Liebig-University Giessen, Giessen, Germany
| | - Werner Seeger
- Institute for Lung Health, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Ryan J Tedford
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - István Vadász
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Rebecca Vanderpool
- Division of Translational and Regenerative Medicine, University of Arizona, Tucson, Arizona
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Manuel J Richter
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Khodr Tello
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany.
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18
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Naeije R, Richter MJ, Rubin LJ. The physiologic basis of pulmonary arterial hypertension. Eur Respir J 2021; 59:13993003.02334-2021. [PMID: 34737219 PMCID: PMC9203839 DOI: 10.1183/13993003.02334-2021] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/18/2021] [Indexed: 11/05/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare dyspnea-fatigue syndrome caused by a progressive increase in pulmonary vascular resistance (PVR) and eventual right ventricular (RV) failure. In spite of extensive pulmonary vascular remodeling, lung function in PAH is generally well preserved, with hyperventilation and increased physiologic dead space, but minimal changes in lung mechanics and only mild to moderate hypoxemia and hypocapnia. Hypoxemia is mainly caused by a low mixed venous PO2 from a decreased cardiac output. Hypocapnia is mainly caused by an increased chemosensitivity. Exercise limitation in PAH is cardiovascular rather than ventilatory or muscular. The extent of pulmonary vascular disease in PAH is defined by multipoint pulmonary vascular pressure-flow relationships with a correction for hematocrit. Pulsatile pulmonary vascular pressure-flow relationships in PAH allow for the assessment of RV hydraulic load. This analysis is possible either in the frequency-domain or in the time-domain. The RV in PAH adapts to increased afterload by an increased contractility to preserve its coupling to the pulmonary circulation. When this homeometric mechanism is exhausted, the RV dilates to preserve flow output by an additional heterometric mechanism. Right heart failure is then diagnosed by imaging of increased right heart dimensions and clinical systemic congestion signs and symptoms. The coupling of the RV to the pulmonary circulation is assessed by the ratio of end-systolic to arterial elastances, but these measurements are difficult. Simplified estimates of RV-PA coupling can be obtained by magnetic resonance or echocardiographic imaging of ejection fraction.
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Affiliation(s)
| | - Manuel J Richter
- Department of Internal Medicine, Justus Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Lewis J Rubin
- University of California, San Diego, La Jolla, CA, USA
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19
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Shang X, Zhang C, Liu M, Lu R, Wang Y. Right ventricular contractility as a potential independent evaluation parameter in pulmonary hypertension. Int J Clin Pract 2021; 75:e14183. [PMID: 33768650 DOI: 10.1111/ijcp.14183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/14/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Pulmonary artery hypertension (PAH) is a common disease with high disability and mortality rates, and can lead to right heart failure. We aimed to evaluate the capability of right ventricular pressure-volume coupling parameters, end-systolic elastance (Ees), right ventricular afterload (Ea), and arterial elastance (Ees/Ea) for assessing right ventricular performance during the chronic development of PAH. METHODS Thirty-six PAH patients were enrolled in this study. We reported the cutoff values of the right ventricular pressure-volume coupling parameters in the progression of PAH and their relations with other pressure-volume loop measurements in both the right and left ventricles. RESULTS Ees and normalised Ees (Ees/Ea) calculated from the pressure method performed better than ones from the volume method in correlation with mean pulmonary arterial pressure and mean right arterial pressure. The cutoff sets of Ees and Ees/Ea were capable of grouping pulmonary hypertension patients which were well supported by their significant correlation with several key right ventricular hemodynamic parameters. Additionally, the normalised Ees was able to reflect the changes in left ventricular function during the deterioration of PAH. CONCLUSION Ees and Ees/Ea are promising independent reference parameters for assessing ventricular function in progressing PAH patients.
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Affiliation(s)
- Xiaoke Shang
- Department of Internal Medicine, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Changdong Zhang
- Department of Internal Medicine, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Mei Liu
- Intensive Care Unit, Wuhan NO. 1 Hospital, Wuhan, China
| | - Rong Lu
- Intensive Care Unit, Wuhan NO. 1 Hospital, Wuhan, China
| | - Yanggan Wang
- Department of Internal Medicine, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
- Medical Research Institute of Wuhan University, Wuhan University, Wuhan, China
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Abstract
The health burden of heart failure with preserved ejection fraction is increasingly recognized. Despite improvements in diagnostic algorithms and established knowledge on the clinical trajectory, effective treatment options for heart failure with preserved ejection fraction remain limited, mainly because of the high mechanistic heterogeneity. Diagnostic scores, big data, and phenomapping categorization are proposed as key steps needed for progress. In the meantime, advancements in imaging techniques combined to high-fidelity pressure signaling analysis have uncovered right ventricular dysfunction as a mediator of heart failure with preserved ejection fraction progression and as major independent determinant of poor outcome. This review summarizes the current understanding of the pathophysiology of right ventricular dysfunction in heart failure with preserved ejection fraction covering the different right heart phenotypes and offering perspectives on new treatments targeting the right ventricle in its function and geometry.
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Affiliation(s)
- Marco Guazzi
- Department of Biological Sciences, University of Milano, Italy (M.G.).,Cardiology Division, San Paolo Hospital, Italy (M.G.)
| | - Robert Naeije
- Erasme Hospital, Free University of Brussels, Belgium (R.N.)
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21
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Hornung A, Vollmer D, Wiegand G, Apitz C, Latus H, Hofbeck M, Sieverding L. A Comprehensive Functional Analysis in Patients after Atrial Switch Surgery. Thorac Cardiovasc Surg 2021; 69:e32-e40. [PMID: 33851400 PMCID: PMC8045928 DOI: 10.1055/s-0041-1726307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Long-term course after atrial switch operation is determined by
increasing right ventricular (RV) insufficiency. The aim of our study was to investigate
subtle functional parameters by invasive measurements with conductance technique and
noninvasive examinations with cardiac magnetic resonance imaging (CMR). Methods We used invasive (pressure–volume loops under baseline conditions and
dobutamine) and noninvasive techniques (CMR with feature tracking [FT] method) to evaluate
RV function. All patients had cardiopulmonary exercise testing (CPET). Results From 2011 to 2013, 16 patients aged 28.2 ± 7.3 (22–50) years after atrial
switch surgery (87.5% Senning and 12.5% Mustard) were enrolled in this prospective study.
All patients were in New York Heart Association (NYHA) class I to II and presented mean
peak oxygen consumption of 30.1 ± 5.7 (22.7–45.5) mL/kg/min. CMR-derived end-diastolic
volume was 110 ± 22 (78–156) mL/m 2 and RV ejection fraction 41 ± 8% (25–52%).
CMR-FT revealed lower global systolic longitudinal, radial, and circumferential strain for
the systemic RV compared with the subpulmonary left ventricle. End-systolic elastance
(Ees) was overall reduced (compared with data from the literature) and showed significant
increase under dobutamine (0.80 ± 0.44 to 1.89 ± 0.72 mm Hg/mL, p ≤ 0.001), whereas
end-diastolic elastance (Eed) was not significantly influenced (0.11 ± 0.70 to
0.13 ± 0.15 mm Hg/mL, p = 0.454). We found no relevant relationship between
load-independent conductance indices and strain or CPET parameters. Conductance analysis
revealed significant mechanical dyssynchrony, higher during diastole (mean 30 ± 4%
baseline, 24 ± 6% dobutamine) than during systole (mean 17 ± 6% baseline, 19 ± 7%
dobutamine). Conclusions Functional assessment of a deteriorating systemic RV remains
demanding. Conductance indices as well as the CMR-derived strain parameters showed overall
reduced values, but a significant relationship was not present (including CPET). Our
conductance analysis revealed intraventricular and predominantly diastolic RV
dyssynchrony.
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Affiliation(s)
- Andreas Hornung
- Department Pediatric Cardiology, Pulmonology and Intensive Care, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Daniela Vollmer
- Department Pediatric Cardiology, Pulmonology and Intensive Care, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Gesa Wiegand
- Department Pediatric Cardiology, Pulmonology and Intensive Care, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Christian Apitz
- Department Pediatric Cardiology, University Children's Hospital Ulm, Ulm, Germany
| | - Heiner Latus
- Department Pediatric Cardiology and Congenital Heart Disease, German Heart Center, Munich, Germany
| | - Michael Hofbeck
- Department Pediatric Cardiology, Pulmonology and Intensive Care, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Ludger Sieverding
- Department Pediatric Cardiology, Pulmonology and Intensive Care, University Children's Hospital Tuebingen, Tuebingen, Germany
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22
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Richter MJ, Hsu S, Yogeswaran A, Husain-Syed F, Vadász I, Ghofrani HA, Naeije R, Harth S, Grimminger F, Seeger W, Gall H, Tedford RJ, Tello K. Right ventricular pressure-volume loop shape and systolic pressure change in pulmonary hypertension. Am J Physiol Lung Cell Mol Physiol 2021; 320:L715-L725. [PMID: 33655769 DOI: 10.1152/ajplung.00583.2020] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Right ventricular (RV) function determines outcome in pulmonary arterial hypertension (PAH). RV pressure-volume loops, the gold standard for measuring RV function, are difficult to analyze. Our aim was to investigate whether simple assessments of RV pressure-volume loop morphology and RV systolic pressure differential reflect PAH severity and RV function. We analyzed multibeat RV pressure-volume loops (obtained by conductance catheterization with preload reduction) in 77 patients with PAH and 15 patients without pulmonary hypertension in two centers. Patients were categorized according to their pressure-volume loop shape (triangular, quadratic, trapezoid, or notched). RV systolic pressure differential was defined as end-systolic minus beginning-systolic pressure (ESP - BSP), augmentation index as ESP - BSP/pulse pressure, pulmonary arterial capacitance (PAC) as stroke volume/pulse pressure, and RV-arterial coupling as end-systolic/arterial elastance (Ees/Ea). Trapezoid and notched pressure-volume loops were associated with the highest afterload (Ea), augmentation index, pulmonary vascular resistance (PVR), mean pulmonary arterial pressure, stroke work, B-type natriuretic peptide, and the lowest Ees/Ea and PAC. Multivariate linear regression identified Ea, PVR, and stroke work as the main determinants of ESP - BSP. ESP - BSP also significantly correlated with multibeat Ees/Ea (Spearman's ρ: -0.518, P < 0.001). A separate retrospective analysis of 113 patients with PAH showed that ESP - BSP obtained by routine right heart catheterization significantly correlated with a noninvasive surrogate of RV-arterial coupling (tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure ratio; ρ: -0.376, P < 0.001). In conclusion, pressure-volume loop shape and RV systolic pressure differential predominately depend on afterload and PAH severity and reflect RV-arterial coupling in PAH.
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Affiliation(s)
- Manuel J Richter
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Athiththan Yogeswaran
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Faeq Husain-Syed
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - István Vadász
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Hossein A Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany.,Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,Department of Medicine, Imperial College London, London, United Kingdom
| | | | - Sebastian Harth
- Department of Radiology, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Friedrich Grimminger
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany.,Institute for Lung Health, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- Institute for Lung Health, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Henning Gall
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Khodr Tello
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
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23
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Right ventricular adaptation to pressure-overload: Differences between chronic thromboembolic pulmonary hypertension and idiopathic pulmonary arterial hypertension. J Heart Lung Transplant 2021; 40:458-466. [PMID: 33745783 DOI: 10.1016/j.healun.2021.02.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/15/2021] [Accepted: 02/25/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) and idiopathic pulmonary arterial hypertension (iPAH) are both associated with right ventricular (RV) failure and mortality. However, CTEPH patients are older, more often male and usually have more co-morbidities than iPAH patients, including a history of venous thromboembolism. Therefore, RV adaptation to pressure-overload in CTEPH may be different than in iPAH. METHODS We included all treatment-naive CTEPH and iPAH patients diagnosed in the Amsterdam UMC between 2000 and 2019 if cardiac magnetic resonance imaging (CMR) and a right heart catheterization were performed at time of diagnosis. Load-dependent RV volumes and mass were assessed with CMR. Load-independent RV contractility, afterload and diastolic stiffness in relation to afterload were obtained using single beat pressure-volume loop analysis. Differences in RV characteristics between CTEPH and iPAH were analyzed using multiple linear regression with interaction testing after correcting for confounders. RESULTS We included 235 patients in this study and performed pressure-volume loop analysis in 136 patients. In addition to being older and more often male, CTEPH patients had a lower pulmonary vascular resistance than iPAH patients at the time of diagnosis. After correcting for these confounders, CTEPH patients had a somewhat higher RV end-diastolic volume index (87 ± 27 ml vs 82 ± 25 ml; p < .01), and a lower RV relative wall thickness (0.6 ± 0,1 g/ml vs 0.7 ± 0,2 g/ml; p < .01). The correlation coefficient of RV diastolic stiffness to afterload was higher in CTEPH compared to iPAH (p < .05; independent of age and gender). CONCLUSIONS Despite differences in patient characteristics, disease etiology and physiology, RV functional parameters in CTEPH and iPAH are mostly similar. The right ventricle in CTEPH is marginally more dilated, stiffer and less hypertrophic than in iPAH.
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24
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Singh S, Lewis MI. Evaluating the Right Ventricle in Acute and Chronic Pulmonary Embolism: Current and Future Considerations. Semin Respir Crit Care Med 2021; 42:199-211. [PMID: 33548932 DOI: 10.1055/s-0040-1722290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The right ventricle (RV), due to its morphologic and physiologic differences, is susceptible to sudden increase in RV afterload, as noted in patients with acute pulmonary embolism (PE). Functional impairment of RV function is a stronger presage of adverse outcomes in acute PE than the location or burden of emboli. While current iterations of most clinical prognostic scores do not incorporate RV dysfunction, advancements in imaging have enabled more granular and accurate assessment of RV dysfunction in acute PE. RV enlargement and dysfunction on imaging is noted only in a subset of patients with acute PE and is dependent on underlying cardiopulmonary reserve and clot burden. Specific signs like McConnell's and "60/60" sign are noted in less than 20% of patients with acute PE. About 2% of patients with acute PE develop chronic thromboembolic pulmonary hypertension, characterized by continued deterioration in RV function in a subset of patients with a continuum of RV function from preserved to overt right heart failure. Advances in molecular and other imaging will help better characterize RV dysfunction in this population and evaluate the response to therapies.
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Affiliation(s)
- Siddharth Singh
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael I Lewis
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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25
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Boon GJAM, Huisman MV, Klok FA. Determinants and Management of the Post-Pulmonary Embolism Syndrome. Semin Respir Crit Care Med 2021; 42:299-307. [PMID: 33548930 DOI: 10.1055/s-0041-1722964] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute pulmonary embolism (PE) is not only a serious and potentially life-threatening disease in the acute phase, in recent years it has become evident that it may also have a major impact on a patient's daily life in the long run. Persistent dyspnea and impaired functional status are common, occurring in up to 50% of PE survivors, and have been termed the post-PE syndrome (PPES). Chronic thromboembolic pulmonary hypertension is the most feared cause of post-PE dyspnea. When pulmonary hypertension is ruled out, cardiopulmonary exercise testing can play a central role in investigating the potential causes of persistent symptoms, including chronic thromboembolic pulmonary disease or other cardiopulmonary conditions. Alternatively, it is important to realize that post-PE cardiac impairment or post-PE functional limitations, including deconditioning, are present in a large proportion of patients. Health-related quality of life is strongly influenced by PPES, which emphasizes the importance of persistent limitations after an episode of acute PE. In this review, physiological determinants and the diagnostic management of persistent dyspnea after acute PE are elucidated.
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Affiliation(s)
- Gudula J A M Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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26
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Tran T, Muralidhar A, Hunter K, Buchanan C, Coe G, Hieda M, Tompkins C, Zipse M, Spotts MJ, Laing SG, Fosmark K, Hoffman J, Ambardekar AV, Wolfel EE, Lawley J, Levine B, Kohrt WM, Pal J, Cornwell WK. Right ventricular function and cardiopulmonary performance among patients with heart failure supported by durable mechanical circulatory support devices. J Heart Lung Transplant 2021; 40:128-137. [PMID: 33281029 DOI: 10.1016/j.healun.2020.11.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/15/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Patients with continuous-flow left ventricular assist devices (CF-LVADs) experience limitations in functional capacity and frequently, right ventricular (RV) dysfunction. We sought to characterize RV function in the context of global cardiopulmonary performance during exercise in this population. METHODS A total of 26 patients with CF-LVAD (aged 58 ± 11 years, 23 males) completed a hemodynamic assessment with either conductance catheters (Group 1, n = 13) inserted into the right ventricle to generate RV pressure‒volume loops or traditional Swan‒Ganz catheters (Group 2, n = 13) during invasive cardiopulmonary exercise testing. Hemodynamics were collected at rest, 2 sub-maximal levels of exercise, and peak effort. Breath-by-breath gas exchange parameters were collected by indirect calorimetry. Group 1 participants also completed an invasive ramp test during supine rest to determine the impact of varying levels of CF-LVAD support on RV function. RESULTS In Group 1, pump speed modulations minimally influenced RV function. During upright exercise, there were modest increases in RV contractility during sub-maximal exercise, but there were no appreciable increases at peak effort. Ventricular‒arterial coupling was preserved throughout the exercise. In Group 2, there were large increases in pulmonary arterial, left-sided filling, and right-sided filling pressures during sub-maximal and peak exercises. Among all participants, the cardiac output‒oxygen uptake relationship was preserved at 5.8:1. Ventilatory efficiency was severely abnormal at 42.3 ± 11.6. CONCLUSIONS Patients with CF-LVAD suffer from limited RV contractile reserve; marked elevations in pulmonary, left-sided filling, and right-sided filling pressures during exercise; and severe ventilatory inefficiency. These findings explain mechanisms for persistent reductions in functional capacity in this patient population.
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Affiliation(s)
- Tomio Tran
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Akshay Muralidhar
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kendall Hunter
- Department of Bioengineering, Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Cullen Buchanan
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Greg Coe
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Michinari Hieda
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Campus, Dallas, Texas; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas Texas
| | - Christine Tompkins
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia
| | - Matthew Zipse
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Melanie J Spotts
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Stephanie G Laing
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kristina Fosmark
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jordan Hoffman
- Department of Cardiac Surgery, Vanderbilt University, Nashville, Tennessee
| | - Amrut V Ambardekar
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Eugene E Wolfel
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Justin Lawley
- Department of Sport Science, University of Innsbruck, Innsbruck, Austria
| | - Benjamin Levine
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Campus, Dallas, Texas; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas Texas
| | - Wendy M Kohrt
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jay Pal
- Department of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - William K Cornwell
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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27
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Wright SP, Dawkins TG, Eves ND, Shave R, Tedford RJ, Mak S. Hemodynamic function of the right ventricular-pulmonary vascular-left atrial unit: normal responses to exercise in healthy adults. Am J Physiol Heart Circ Physiol 2020; 320:H923-H941. [PMID: 33356960 DOI: 10.1152/ajpheart.00720.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
With each heartbeat, the right ventricle (RV) inputs blood into the pulmonary vascular (PV) compartment, which conducts blood through the lungs at low pressure and concurrently fills the left atrium (LA) for output to the systemic circulation. This overall hemodynamic function of the integrated RV-PV-LA unit is determined by complex interactions between the components that vary over the cardiac cycle but are often assessed in terms of mean pressure and flow. Exercise challenges these hemodynamic interactions as cardiac filling increases, stroke volume augments, and cycle length decreases, with PV pressures ultimately increasing in association with cardiac output. Recent cardiopulmonary exercise hemodynamic studies have enriched the available data from healthy adults, yielded insight into the underlying mechanisms that modify the PV pressure-flow relationship, and better delineated the normal limits of healthy responses to exercise. This review will examine hemodynamic function of the RV-PV-LA unit using the two-element Windkessel model for the pulmonary circulation. It will focus on acute PV and LA responses that accommodate increased RV output during exercise, including PV recruitment and distension and LA reservoir expansion, and the integrated mean pressure-flow response to exercise in healthy adults. Finally, it will consider how these responses may be impacted by age-related remodeling and modified by sex-related cardiopulmonary differences. Studying the determinants and recognizing the normal limits of PV pressure-flow relations during exercise will improve our understanding of cardiopulmonary mechanisms that facilitate or limit exercise.
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Affiliation(s)
- S P Wright
- Centre for Heart, Lung and Vascular Health, University of British Columbia-Okanagan, Kelowna, British Columbia, Canada
| | - T G Dawkins
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, Wales, United Kingdom
| | - N D Eves
- Centre for Heart, Lung and Vascular Health, University of British Columbia-Okanagan, Kelowna, British Columbia, Canada
| | - R Shave
- Centre for Heart, Lung and Vascular Health, University of British Columbia-Okanagan, Kelowna, British Columbia, Canada
| | - R J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - S Mak
- Division of Cardiology, Department of Medicine, Sinai Health, Toronto, Ontario, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Cornwell WK, Tran T, Cerbin L, Coe G, Muralidhar A, Hunter K, Altman N, Ambardekar AV, Tompkins C, Zipse M, Schulte M, O'Gean K, Ostertag M, Hoffman J, Pal JD, Lawley JS, Levine BD, Wolfel E, Kohrt WM, Buttrick P. New insights into resting and exertional right ventricular performance in the healthy heart through real-time pressure-volume analysis. J Physiol 2020; 598:2575-2587. [PMID: 32347547 DOI: 10.1113/jp279759] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 04/20/2020] [Indexed: 02/02/2024] Open
Abstract
KEY POINTS Despite growing interest in right ventricular form and function in diseased states, there is a paucity of data regarding characteristics of right ventricular function - namely contractile and lusitropic reserve, as well as ventricular-arterial coupling, in the healthy heart during rest, as well as submaximal and peak exercise. Pressure-volume analysis of the right ventricle, during invasive cardiopulmonary exercise testing, demonstrates that that the right heart has enormous contractile reserve, with a three- or fourfold increase in all metrics of contractility, as well as myocardial energy production and utilization. The healthy right ventricle also demonstrates marked augmentation in lusitropy, indicating that diastolic filling of the right heart is not passive. Rather, the right ventricle actively contributes to venous return during exercise, along with the muscle pump. Ventricular-arterial coupling is preserved during submaximal and peak exercise in the healthy heart. ABSTRACT Knowledge of right ventricular (RV) function has lagged behind that of the left ventricle and historically, the RV has even been referred to as a 'passive conduit' of lesser importance than its left-sided counterpart. Pressure-volume (PV) analysis is the gold standard metric of assessing ventricular performance. We recruited nine healthy sedentary individuals free of any cardiopulmonary disease (42 ± 12 years, 78 ± 11 kg), who completed invasive cardiopulmonary exercise testing during upright ergometry, while using conductance catheters inserted into the RV to generate real-time PV loops. Data were obtained at rest, two submaximal levels of exercise below ventilatory threshold, to simulate real-world scenarios/activities of daily living, and maximal effort. Breath-by-breath oxygen uptake was determined by indirect calorimetry. During submaximal and peak exercise, there were significant increases in all metrics of systolic function by three- to fourfold, including cardiac output, preload recruitable stroke work, and maximum rate of pressure change in the ventricle (dP/dtmax ), as well as energy utilization as determined by stroke work and pressure-volume area. Similarly, the RV demonstrated a significant, threefold increase in lusitropic reserve throughout exercise. Ventricular-arterial coupling, defined by the quotient of end-systolic elastance and effective arterial elastance, was preserved throughout all stages of exercise. Maximal pressures increased significantly during exercise, while end-diastolic volumes were essentially unchanged. Overall, these findings demonstrate that the healthy RV is not merely a passive conduit, but actively participates in cardiopulmonary performance during exercise by accessing an enormous amount of contractile and lusitropic reserve, ensuring that VA coupling is preserved throughout all stages of exercise.
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Affiliation(s)
- William K Cornwell
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Clinical and Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Tomio Tran
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lukasz Cerbin
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Greg Coe
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Akshay Muralidhar
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kendall Hunter
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Natasha Altman
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Amrut V Ambardekar
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Christine Tompkins
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew Zipse
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Margaret Schulte
- Clinical and Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Katie O'Gean
- Clinical and Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Morgan Ostertag
- Clinical and Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jordan Hoffman
- Department of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jay D Pal
- Department of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Justin S Lawley
- Department of Sport Science, University of Innsbruck, Innsbruck, Austria
| | - Benjamin D Levine
- University of Texas Southwestern Medical Campus, Dallas, TX, USA
- Texas Health Presbyterian Hospital, Institute for Exercise and Environmental Medicine, Dallas, TX, USA
| | - Eugene Wolfel
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Wendy M Kohrt
- Clinical and Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Medicine, Division of Geriatric Medicine and Eastern Colorado VA Geriatric Research Education and Clinical Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Peter Buttrick
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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30
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McCabe C, Dimopoulos K, Pitcher A, Orchard E, Price LC, Kempny A, Wort SJ. Chronic thromboembolic disease following pulmonary embolism: time for a fresh look at old clot. Eur Respir J 2020; 55:55/4/1901934. [DOI: 10.1183/13993003.01934-2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 01/24/2020] [Indexed: 01/16/2023]
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31
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Richter MJ, Fortuni F, Wiegand MA, Dalmer A, Vanderpool R, Ghofrani HA, Naeije R, Roller F, Seeger W, Sommer N, Gall H, Ghio S, Tello K. Association of right atrial conduit phase with right ventricular lusitropic function in pulmonary hypertension. Int J Cardiovasc Imaging 2020; 36:633-642. [DOI: 10.1007/s10554-019-01763-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 12/27/2019] [Indexed: 12/21/2022]
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Tello K, Seeger W, Naeije R, Vanderpool R, Ghofrani HA, Richter M, Tedford RJ, Bogaard HJ. Right heart failure in pulmonary hypertension: Diagnosis and new perspectives on vascular and direct right ventricular treatment. Br J Pharmacol 2019; 178:90-107. [PMID: 31517994 DOI: 10.1111/bph.14866] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/15/2019] [Accepted: 09/04/2019] [Indexed: 12/18/2022] Open
Abstract
Adaptation of right ventricular (RV) function to increased afterload-known as RV-arterial coupling-is a key determinant of prognosis in pulmonary hypertension. However, measurement of RV-arterial coupling is a complex, invasive process involving analysis of the RV pressure-volume relationship during preload reduction over multiple cardiac cycles. Simplified methods have therefore been proposed, including echocardiographic and cardiac MRI approaches. This review describes the available methods for assessment of RV function and RV-arterial coupling and the effects of pharmacotherapy on these variables. Overall, pharmacotherapies for pulmonary hypertension have shown beneficial effects on various measures of RV function, but it is often unclear if these are direct RV effects or indirect results of afterload reduction. Studies of the effects of pharmacotherapies on RV-arterial coupling are limited and mostly restricted to experimental models. Simplified methods to assess RV-arterial coupling should be validated and incorporated into routine clinical follow-up and future clinical trials. LINKED ARTICLES: This article is part of a themed issue on Risk factors, comorbidities, and comedications in cardioprotection. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.1/issuetoc.
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Affiliation(s)
- Khodr Tello
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Robert Naeije
- Physiology, Erasme University Hospital, Brussels, Belgium
| | | | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Manuel Richter
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina (MUSC), Charleston, SC, USA
| | - Harm J Bogaard
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Vandenheuvel M, Bouchez S, Wouters P, Mauermann E. Assessing Right Ventricular Function in the Perioperative Setting, Part II: What About Catheters? Anesthesiol Clin 2019; 37:697-712. [PMID: 31677686 DOI: 10.1016/j.anclin.2019.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
An-depth assessment of right ventricular function is important in a many perioperative settings. After exploring 2-dimensional echo-based evaluation, other proposed monitoring modalities are discussed. Pressure-based methods of right ventricular appraisal is discussed. Flow-based assessment is reviewed. An overview of the state of current right ventricular 3-dimensional echocardiography and its potential to construct clinical pressure-volume loops in conjunction with pressure measurements is provided. An overview of right ventricular assessment modalities that do not rely on 2-dimensional echocardiography is discussed. Tailored selection of monitoring modalities can be of great benefit for the perioperative physician. Integrating modalities offers optimal estimations of right ventricular function.
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Affiliation(s)
- Michael Vandenheuvel
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Stefaan Bouchez
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Patrick Wouters
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium
| | - Eckhard Mauermann
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, C. Heymanslaan 10, Ghent 9000, Belgium; Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, Basel University Hospital, Spitalstrasse 21, Basel 4031, Switzerland.
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Welt FGP, Fang JC. Pressure Volume System for Management of Heart Failure and Valvular Heart Disease. Curr Cardiol Rep 2019; 21:153. [PMID: 31768659 DOI: 10.1007/s11886-019-1247-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW To introduce the reader to the basics of pressure-volume (PV) analysis, its current role in management of heart failure and valvular disease, and the possibilities for future use. RECENT FINDINGS The recent introduction of FDA-approved miniaturized conductance catheters that can produce PV loops in the clinical setting has set the stage for the translation of this important research technique into clinical practice. The use of these catheters has shed important insights into the pathophysiology of many common conditions associated with heart failure including heart failure with preserved ejection fraction and right heart failure and has been utilized to assist in optimization of lead placement during cardiac resynchronization therapy. The use of PV loops has enhanced our understanding and diagnosis of common conditions associated with heart failure. In addition, it has shown promise as an adjunct to therapeutic procedures. Future directions may include the use of PV loops in the management of patients with heart failure requiring mechanical circulatory support and to help predict the utility of percutaneous valvular interventions.
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Affiliation(s)
- Frederick G P Welt
- Division of Cardiovascular Medicine, University of Utah Health, 30 North 1900 East, Room 4A100, Salt Lake City, Utah, 84132, USA.
| | - James C Fang
- Division of Cardiovascular Medicine, University of Utah Health, 30 North 1900 East, Room 4A100, Salt Lake City, Utah, 84132, USA
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Tello K, Gall H, Richter M, Ghofrani A, Schermuly R. Right ventricular function in pulmonary (arterial) hypertension. Herz 2019; 44:509-516. [PMID: 31101945 DOI: 10.1007/s00059-019-4815-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The right ventricle (RV) is the main determinant of prognosis in pulmonary hypertension. Adaptation and maladaptation of the RV are of crucial importance. In the course of disease, RV contractility increases through changes in muscle properties and muscle hypertrophy. At a certain point, the point of "uncoupling," the afterload exceeds contractility, and maladaptation as well as dilation occurs to maintain stroke volume (SV). To understand the adaptational processes and to further develop targeted medication directly affecting load-independent contractility, an accurate and precise assessment of contractility and RV-pulmonary artery (PA) coupling should be performed. In this review, we shed light on existing methods to assess RV function, including the gold standard measurement of contractility and RV-PA coupling, and we evaluate existing surrogates of RV-PA coupling.
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Affiliation(s)
- K Tello
- Department of Internal Medicine, Universities of Gießen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University Gießen, Klinikstraße 32, 35392, Gießen, Germany.
| | - H Gall
- Department of Internal Medicine, Universities of Gießen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University Gießen, Klinikstraße 32, 35392, Gießen, Germany
| | - M Richter
- Department of Internal Medicine, Universities of Gießen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University Gießen, Klinikstraße 32, 35392, Gießen, Germany
| | - A Ghofrani
- Department of Internal Medicine, Universities of Gießen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University Gießen, Klinikstraße 32, 35392, Gießen, Germany
| | - R Schermuly
- Department of Internal Medicine, Universities of Gießen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University Gießen, Klinikstraße 32, 35392, Gießen, Germany
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Lahm T, Douglas IS, Archer SL, Bogaard HJ, Chesler NC, Haddad F, Hemnes AR, Kawut SM, Kline JA, Kolb TM, Mathai SC, Mercier O, Michelakis ED, Naeije R, Tuder RM, Ventetuolo CE, Vieillard-Baron A, Voelkel NF, Vonk-Noordegraaf A, Hassoun PM. Assessment of Right Ventricular Function in the Research Setting: Knowledge Gaps and Pathways Forward. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2019; 198:e15-e43. [PMID: 30109950 DOI: 10.1164/rccm.201806-1160st] [Citation(s) in RCA: 203] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Right ventricular (RV) adaptation to acute and chronic pulmonary hypertensive syndromes is a significant determinant of short- and long-term outcomes. Although remarkable progress has been made in the understanding of RV function and failure since the meeting of the NIH Working Group on Cellular and Molecular Mechanisms of Right Heart Failure in 2005, significant gaps remain at many levels in the understanding of cellular and molecular mechanisms of RV responses to pressure and volume overload, in the validation of diagnostic modalities, and in the development of evidence-based therapies. METHODS A multidisciplinary working group of 20 international experts from the American Thoracic Society Assemblies on Pulmonary Circulation and Critical Care, as well as external content experts, reviewed the literature, identified important knowledge gaps, and provided recommendations. RESULTS This document reviews the knowledge in the field of RV failure, identifies and prioritizes the most pertinent research gaps, and provides a prioritized pathway for addressing these preclinical and clinical questions. The group identified knowledge gaps and research opportunities in three major topic areas: 1) optimizing the methodology to assess RV function in acute and chronic conditions in preclinical models, human studies, and clinical trials; 2) analyzing advanced RV hemodynamic parameters at rest and in response to exercise; and 3) deciphering the underlying molecular and pathogenic mechanisms of RV function and failure in diverse pulmonary hypertension syndromes. CONCLUSIONS This statement provides a roadmap to further advance the state of knowledge, with the ultimate goal of developing RV-targeted therapies for patients with RV failure of any etiology.
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Claeys M, Claessen G, La Gerche A, Petit T, Belge C, Meyns B, Bogaert J, Willems R, Claus P, Delcroix M. Impaired Cardiac Reserve and Abnormal Vascular Load Limit Exercise Capacity in Chronic Thromboembolic Disease. JACC Cardiovasc Imaging 2019; 12:1444-1456. [DOI: 10.1016/j.jcmg.2018.07.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 07/20/2018] [Accepted: 07/23/2018] [Indexed: 01/14/2023]
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Stam K, Cai Z, van der Velde N, van Duin R, Lam E, van der Velden J, Hirsch A, Duncker DJ, Merkus D. Cardiac remodelling in a swine model of chronic thromboembolic pulmonary hypertension: comparison of right vs. left ventricle. J Physiol 2019; 597:4465-4480. [PMID: 31194256 PMCID: PMC6852085 DOI: 10.1113/jp277896] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 06/07/2019] [Indexed: 12/11/2022] Open
Abstract
Key points Right ventricle (RV) function is the most important determinant of survival and quality of life in patients with chronic thromboembolic pulmonary hypertension (CTEPH). The changes in right and left ventricle gene expression that contribute to ventricular remodelling are incompletely investigated. RV remodelling in our CTEPH swine model is associated with increased expression of the genes involved in inflammation (TGFβ), oxidative stress (ROCK2, NOX1 and NOX4), and apoptosis (BCL2 and caspase‐3). Alterations in ROCK2 expression correlated inversely with RV contractile reserve during exercise. Since ROCK2 has been shown to be involved in hypertrophy, oxidative stress, fibrosis and endothelial dysfunction, ROCK2 inhibition may present a viable therapeutic target in CTEPH.
Abstract Right ventricle (RV) function is the most important determinant of survival and quality of life in patients with chronic thromboembolic pulmonary hypertension (CTEPH). The present study investigated whether the increased cardiac afterload is associated with (i) cardiac remodelling and hypertrophic signalling; (ii) changes in angiogenic factors and capillary density; and (iii) inflammatory changes associated with oxidative stress and interstitial fibrosis. CTEPH was induced in eight chronically instrumented swine by chronic nitric oxide synthase inhibition and up to five weekly pulmonary embolizations. Nine healthy swine served as a control. After 9 weeks, RV function was assessed by single beat analysis of RV–pulmonary artery (PA) coupling at rest and during exercise, as well as by cardiac magnetic resonance imaging. Subsequently, the heart was excised and RV and left ventricle (LV) tissues were processed for molecular and histological analyses. Swine with CTEPH exhibited significant RV hypertrophy in response to the elevated PA pressure. RV–PA coupling was significantly reduced, correlated inversely with pulmonary vascular resistance and did not increase during exercise in CTEPH swine. Expression of genes associated with hypertrophy (BNP), inflammation (TGFβ), oxidative stress (ROCK2, NOX1 and NOX4), apoptosis (BCL2 and caspase‐3) and angiogenesis (VEGFA) were increased in the RV of CTEPH swine and correlated inversely with RV–PA coupling during exercise. In the LV, only significant changes in ROCK2 gene‐expression occurred. In conclusion, RV remodelling in our CTEPH swine model is associated with increased expression of genes involved in inflammation and oxidative stress, suggesting that these processes contribute to RV remodelling and dysfunction in CTEPH and hence represent potential therapeutic targets. Right ventricle (RV) function is the most important determinant of survival and quality of life in patients with chronic thromboembolic pulmonary hypertension (CTEPH). The changes in right and left ventricle gene expression that contribute to ventricular remodelling are incompletely investigated. RV remodelling in our CTEPH swine model is associated with increased expression of the genes involved in inflammation (TGFβ), oxidative stress (ROCK2, NOX1 and NOX4), and apoptosis (BCL2 and caspase‐3). Alterations in ROCK2 expression correlated inversely with RV contractile reserve during exercise. Since ROCK2 has been shown to be involved in hypertrophy, oxidative stress, fibrosis and endothelial dysfunction, ROCK2 inhibition may present a viable therapeutic target in CTEPH.
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Affiliation(s)
- Kelly Stam
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Zongye Cai
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nikki van der Velde
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Richard van Duin
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Esther Lam
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jolanda van der Velden
- Amsterdam UMC, Vrije Universiteit Amsterdam, Physiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Alexander Hirsch
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dirk J Duncker
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Daphne Merkus
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Sydykov A, Muratali Uulu K, Maripov A, Cholponbaeva M, Khan T, Sarybaev A. A Case of Chronic Thromboembolic Pulmonary Hypertension in a High-Altitude Dweller. High Alt Med Biol 2019; 20:303-306. [PMID: 31264887 DOI: 10.1089/ham.2018.0132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Chronic hypoxia causes sustained pulmonary vasoconstriction and vascular remodeling leading to development of pulmonary hypertension in high-altitude residents. Although pulmonary hypertension is of mild to moderate degrees in most cases, some high-altitude residents may develop severe pulmonary hypertension. We report a case of a 47-year-old female highlander of Kyrgyz ethnicity who presented with exertional breathlessness and echocardiographic signs of severe pulmonary hypertension, who was diagnosed as having chronic thromboembolic pulmonary hypertension (CTEPH). To the best of our knowledge, this is the first documented case of severe CTEPH in a high-altitude dweller. This case illustrates that causes other than hypoxia may underlie and/or contribute to severe pulmonary hypertension in residents of high altitude.
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Affiliation(s)
- Akylbek Sydykov
- Department of Mountain and Sleep Medicine and Pulmonary Hypertension, National Center of Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
- Department of Internal Medicine, University of Giessen and Marburg Lung Center (UGMLC), Justus Liebig University of Giessen, Giessen, Germany
| | - Kubatbek Muratali Uulu
- Department of Mountain and Sleep Medicine and Pulmonary Hypertension, National Center of Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
- Kyrgyz-Indian Mountain Biomedical Research Center, Bishkek, Kyrgyzstan
| | - Abdirashit Maripov
- Department of Mountain and Sleep Medicine and Pulmonary Hypertension, National Center of Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
- Kyrgyz-Indian Mountain Biomedical Research Center, Bishkek, Kyrgyzstan
| | - Meerim Cholponbaeva
- Department of Mountain and Sleep Medicine and Pulmonary Hypertension, National Center of Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
- Kyrgyz-Indian Mountain Biomedical Research Center, Bishkek, Kyrgyzstan
| | - Tatyana Khan
- Department of Radiology, National Center of Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
| | - Akpay Sarybaev
- Department of Mountain and Sleep Medicine and Pulmonary Hypertension, National Center of Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
- Kyrgyz-Indian Mountain Biomedical Research Center, Bishkek, Kyrgyzstan
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Abstract
Objective: Chronic thromboembolic disease (CTED) is characterized by persistent pulmonary thromboembolic occlusions without pulmonary hypertension. Early surgical treatment by performing pulmonary endarterectomy (PEA) may improve symptoms. The goal of the study was to review our experience and early outcome of PEA in patients with CTED. Methods: Data were prospectively collected on all patients who underwent PEA between 2011 and 2015. Patients with CTED and a mean pulmonary artery pressure (mPAP) of <25 mm Hg were identified. All patients were in New York Heart Association (NYHA) functional class II or III. Measured outcomes were in-hospital complications, improvement in cardiac function and exercise capacity, and survival after PEA. Patients were reassessed at 6 months following surgery. Results: A total of 23 patients underwent surgery. There was no in-hospital mortality, but complications occurred in six patients (26%). At 6 months following surgery, 93% of the patients remained alive. Following PEA, the mPAP fell significantly from 21.0±2.7 mm Hg to 18.2±5.5 mm Hg (p<.001). Pulmonary vascular resistance also significantly decreased from 2.2±0.7 wood to 1.5±0.5 wood (p<.001). The 6-min walking distance significantly increased from 322.6±80.4 m to 379.9±68.2 m (p<.001). There was a significant symptomatic improvement in all survivors in NYHA functional classes I or II at 6 months following surgery (p=.001). Conclusion: PEA in selected patients with CTED resulted in significant improvement in symptoms. The selection of patients for undergoing PEA in the absence of pulmonary hypertension must be made based on patients’ expectations and their acceptance of the perioperative risk.
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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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Giblett JP, Axell RG, White PA, Aetesam-Ur-Rahman M, Clarke SJ, Figg N, Bennett MR, West NEJ, Hoole SP. Glucagon-Like Peptide-1-Mediated Cardioprotection Does Not Reduce Right Ventricular Stunning and Cumulative Ischemic Dysfunction After Coronary Balloon Occlusion. ACTA ACUST UNITED AC 2019; 4:222-233. [PMID: 31061924 PMCID: PMC6488814 DOI: 10.1016/j.jacbts.2018.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 11/28/2022]
Abstract
GLP-1 protects against ischemic left ventricular dysfunction after serial coronary balloon occlusion of the left anterior descending artery This study assessed whether serial right coronary artery balloon occlusion affected the right ventricle in a similar fashion using a conductance catheter method Serial balloon occlusion of the right coronary artery causes stunning and cumulative ischemic dysfunction in the right ventricle GLP-1 did not protect against stunning and cumulative ischemic dysfunction in the right ventricle
Stunning and cumulative ischemic dysfunction occur in the left ventricle with coronary balloon occlusion. Glucagon-like peptide (GLP)-1 protects the left ventricle against this dysfunction. This study used a conductance catheter method to evaluate whether the right ventricle (RV) developed similar dysfunction during right coronary artery balloon occlusion and whether GLP-1 was protective. In this study, the RV underwent significant stunning and cumulative ischemic dysfunction with right coronary artery balloon occlusion. However, GLP-1 did not protect the RV against this dysfunction when infused after balloon occlusion.
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Key Words
- BL, baseline
- BO1, first balloon occlusion
- BO2, second balloon occlusion
- DSHB, Developmental Studies Hybridoma Bank
- EDP, end-diastolic pressure
- GLP, glucagon-like peptide
- GLP-1R, glucagon-like peptide 1 receptor
- LV, left ventricular
- PCI, percutaneous coronary intervention
- PV, pressure–volume
- RCA, right coronary artery
- RV, right ventricular
- Tau, time constant of diastolic relaxation
- cardioprotection
- dP/dtmax, maximal rate of isovolumetric contraction
- dP/dtmin, maximal rate of isovolumetric relaxation
- glucagon-like peptide-1
- ischemia-reperfusion injury
- right ventricle
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Affiliation(s)
- Joel P Giblett
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, United Kingdom.,Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Richard G Axell
- Medical Physics and Clinical Engineering, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Paul A White
- Medical Physics and Clinical Engineering, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Muhammad Aetesam-Ur-Rahman
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, United Kingdom.,Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Sophie J Clarke
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Nicola Figg
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Martin R Bennett
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Nick E J West
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Stephen P Hoole
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, United Kingdom.,Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
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Bryce YC, Perez-Johnston R, Bryce EB, Homayoon B, Santos-Martin EG. Pathophysiology of right ventricular failure in acute pulmonary embolism and chronic thromboembolic pulmonary hypertension: a pictorial essay for the interventional radiologist. Insights Imaging 2019; 10:18. [PMID: 30758687 PMCID: PMC6375098 DOI: 10.1186/s13244-019-0695-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 01/15/2019] [Indexed: 12/18/2022] Open
Abstract
Pulmonary embolus (PE) is the third most common cause of cardiovascular death with more than 600,000 cases occurring in the USA per year. About 45% of patients with acute PE will have acute right ventricular failure, and up to 3.8% of patients will develop chronic thromboembolic pulmonary hypertension (CTEPH) with progressive, severe, chronic heart failure. The right ventricle (RV) is constructed to accommodate a low-resistance afterload. Increases in afterload from acute massive and submassive PE and CTEPH may markedly compromise the RV function leading to hemodynamic collapse and death. The purpose of this educational manuscript is to instruct on the pathophysiology of RV failure in massive and submassive PE and CTEPH. It is important to understand the pathophysiology of these diseases as it provides the rationale for therapeutic intervention by the Interventional Radiologist. We review here the pathophysiology of right ventricular (RV) failure in acute massive and submassive PE and CTEPH.
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Affiliation(s)
- Yolanda C Bryce
- Radiology Department, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
| | - Rocio Perez-Johnston
- Radiology Department, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Errol B Bryce
- Internal Medicine, Health Science Center, University of North Texas, 1622 8th Ave, Suite 110, Fort Worth, TX, 76104, USA
| | - Behrang Homayoon
- Radiology Department, University of British Columbia, 13750 96th Ave, Surrey, BC, V3V 1Z2, Canada
| | - Ernesto G Santos-Martin
- Radiology Department, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
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44
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Vonk Noordegraaf A, Chin KM, Haddad F, Hassoun PM, Hemnes AR, Hopkins SR, Kawut SM, Langleben D, Lumens J, Naeije R. Pathophysiology of the right ventricle and of the pulmonary circulation in pulmonary hypertension: an update. Eur Respir J 2019; 53:13993003.01900-2018. [PMID: 30545976 PMCID: PMC6351344 DOI: 10.1183/13993003.01900-2018] [Citation(s) in RCA: 283] [Impact Index Per Article: 56.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/09/2018] [Indexed: 01/07/2023]
Abstract
The function of the right ventricle determines the fate of patients with pulmonary hypertension. Since right heart failure is the consequence of increased afterload, a full physiological description of the cardiopulmonary unit consisting of both the right ventricle and pulmonary vascular system is required to interpret clinical data correctly. Here, we provide such a description of the unit and its components, including the functional interactions between the right ventricle and its load. This physiological description is used to provide a framework for the interpretation of right heart catheterisation data as well as imaging data of the right ventricle obtained by echocardiography or magnetic resonance imaging. Finally, an update is provided on the latest insights in the pathobiology of right ventricular failure, including key pathways of molecular adaptation of the pressure overloaded right ventricle. Based on these outcomes, future directions for research are proposed. State of the art and research perspectives in pathophysiology of the right ventricle and of the pulmonary circulation in pulmonary hypertension with theoretical and practical aspectshttp://ow.ly/18v830mgLiP
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Affiliation(s)
- Anton Vonk Noordegraaf
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Kelly Marie Chin
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - François Haddad
- Division of Cardiovascular Medicine, Stanford University and Stanford Cardiovascular Institute, Palo Alto, CA, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Steven Mark Kawut
- Penn Cardiovascular Institute, Dept of Medicine, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David Langleben
- Center for Pulmonary Vascular Disease, Cardiology Division, Jewish General Hospital and McGill University, Montreal, QC, Canada
| | - Joost Lumens
- Maastricht University Medical Center, CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands.,Université de Bordeaux, LIRYC (L'Institut de Rythmologie et Modélisation Cardiaque), Bordeaux, France
| | - Robert Naeije
- Dept of Cardiology, Erasme University Hospital, Brussels, Belgium.,Laboratory of Cardiorespiratory Exercise Physiology, Faculty of Motor Sciences, Université Libre de Bruxelles, Brussels, Belgium
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45
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Swietlik EM, Ruggiero A, Fletcher AJ, Taboada D, Knightbridge E, Harlow L, Harvey I, Screaton N, Cannon JE, Sheares KKK, Ng C, Jenkins DP, Pepke-Zaba J, Toshner MR. Limitations of resting haemodynamics in chronic thromboembolic disease without pulmonary hypertension. Eur Respir J 2019; 53:13993003.01787-2018. [PMID: 30409818 DOI: 10.1183/13993003.01787-2018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 10/18/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Emilia Maria Swietlik
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.,University of Cambridge, Dept of Medicine, Cambridge, UK.,University of Warmia and Mazury, Olsztyn, Poland
| | | | | | | | | | - Louise Harlow
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Ian Harvey
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | - John E Cannon
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | - Choo Ng
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | | | - Mark R Toshner
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.,University of Cambridge, Dept of Medicine, Cambridge, UK
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46
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Abstract
The most common cause of right heart failure is increased afterload caused by pulmonary hypertension. Right ventricular function adaptation to increased afterload is basically systolic, with secondary increase in dimensions and systemic congestion. Increased right ventricular dimensions and decreased ejection fraction are associated with a decreased survival in severe pulmonary hypertension. Targeted therapies titrated to reverse the right ventricular remodeling dimensions improve survival in severe pulmonary hypertension.
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47
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Opotowsky AR, Wertheim BM, Tedford RJ. Not Quite Chronic Thromboembolic Pulmonary Hypertension But More Than a SOB Story. JACC Cardiovasc Imaging 2018; 12:1457-1459. [PMID: 30219406 DOI: 10.1016/j.jcmg.2018.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Alexander R Opotowsky
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Bradley M Wertheim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
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48
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van Loon LM, van der Hoeven JG, Veltink PH, Lemson J. The influence of esmolol on right ventricular function in early experimental endotoxic shock. Physiol Rep 2018; 6:e13882. [PMID: 30318855 PMCID: PMC6186817 DOI: 10.14814/phy2.13882] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/10/2018] [Accepted: 09/11/2018] [Indexed: 11/24/2022] Open
Abstract
The mechanism by which heart rate (HR) control with esmolol improves hemodynamics during septic shock remains unclear. Improved right ventricular (RV) function, thereby reducing venous congestion, may play a role. We assessed the effect of HR control with esmolol during sepsis on RV function, macrocirculation, microcirculation, end-organ-perfusion, and ventricular-arterial coupling. Sepsis was induced in 10 healthy anesthetized and mechanically ventilated sheep by continuous IV administration of lipopolysaccharide (LPS). Esmolol was infused after successful resuscitation of the septic shock, to reduce HR and stopped 30-min after reaching targeted HR reduction of 30%. Venous and arterial blood gases were sampled and the small intestines' microcirculation was assessed by using a hand-held video microscope (CytoCam-IDF). Arterial and venous pressures, and cardiac output (CO) were recorded continuously. An intraventricular micromanometer was used to assess the RV function. Ventricular-arterial coupling ratio (VACR) was estimated by catheterization-derived single beat estimation. The targeted HR reduction of >30% by esmolol infusion, after controlled resuscitation of the LPS induced septic shock, led to a deteriorated RV-function and macrocirculation, while the microcirculation remained depressed. Esmolol improved VACR by decreasing the RV end-systolic pressure. Stopping esmolol showed the reversibility of these effects on the RV and the macrocirculation. In this animal model of acute severe endotoxic septic shock, early administration of esmolol decreased RV-function resulting in venous congestion and an unimproved poor microcirculation despite improved cardiac mechanical efficiency.
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Affiliation(s)
- Lex M. van Loon
- Biomedical Signals and SystemsFaculty of Electrical Engineering, Mathematics and Computer ScienceTechnical Medical CentreUniversity of TwenteEnschedethe Netherlands
- Department of Critical Care Medicine (707)Radboud university medical centerNijmegenthe Netherlands
| | | | - Peter H. Veltink
- Biomedical Signals and SystemsFaculty of Electrical Engineering, Mathematics and Computer ScienceTechnical Medical CentreUniversity of TwenteEnschedethe Netherlands
| | - Joris Lemson
- Department of Critical Care Medicine (707)Radboud university medical centerNijmegenthe Netherlands
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49
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Tabima DM, Philip JL, Chesler NC. Right Ventricular-Pulmonary Vascular Interactions. Physiology (Bethesda) 2018; 32:346-356. [PMID: 28814495 DOI: 10.1152/physiol.00040.2016] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 06/16/2017] [Accepted: 07/06/2017] [Indexed: 11/22/2022] Open
Abstract
Accurate and comprehensive evaluation of right ventricular (RV)-pulmonary vascular (PV) interactions is critical to the assessment of cardiopulmonary function, dysfunction, and failure. Here, we review methods of quantifying RV-PV interactions and experimental results from clinical trials as well as large- and small-animal models based on pressure-volume analysis. We conclude by outlining critical gaps in knowledge that should drive future studies.
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Affiliation(s)
- Diana M Tabima
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, Wisconsin; and
| | - Jennifer L Philip
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, Wisconsin; and.,Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| | - Naomi C Chesler
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, Wisconsin; and
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50
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an uncommon and late complication of pulmonary embolism resulting from misguided remodelling of residual pulmonary thromboembolic material and small-vessel arteriopathy. CTEPH is the only form of pulmonary hypertension (PH) potentially curable by pulmonary endarterectomy (PEA). Unfortunately, several patients have either an unacceptable risk-benefit ratio for undergoing the surgical intervention or develop persistent PH after PEA. Novel medical and endovascular therapies can be considered for them. The soluble guanylate cyclase stimulator riociguat is recommended for the treatment of patients with inoperable disease or with recurrent/persistent PH after PEA. Other drugs developed for the treatment of other forms of PH, as prostanoids, phosphodiesterase-5 inhibitors and endothelin receptor antagonists have been used in the treatment of CTEPH, with limited benefit. Balloon pulmonary angioplasty is a novel and promising technique and is progressively emerging from the pioneering phase. Highly specialized training level and complex protocols of postoperative care are mandatory to consolidate the technical success of the surgical and endovascular intervention.
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Affiliation(s)
| | - Paolo Prandoni
- Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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