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Ambade AS, Naranjo M, Tuhy T, Yu R, Marimoutou M, Everett AD, Shimoda LA, Zimmerman SL, Cubero Salazar IM, Simpson CE, Tedford RJ, Hsu S, Hassoun PM, Damico RL. Collagen 18A1/Endostatin Expression in the Progression of Right Ventricular Remodeling and Dysfunction in Pulmonary Arterial Hypertension. Am J Respir Cell Mol Biol 2024; 71:343-355. [PMID: 38861354 DOI: 10.1165/rcmb.2024-0039oc] [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: 01/26/2024] [Accepted: 06/11/2024] [Indexed: 06/13/2024] Open
Abstract
Numerous studies have demonstrated that endostatin (ES), a potent angiostatic peptide derived from collagen type XVIII α 1 chain and encoded by COL18A1, is elevated in pulmonary arterial hypertension (PAH). It is important to note that elevated ES has consistently been associated with altered hemodynamics, poor functional status, and adverse outcomes in adult and pediatric PAH. This study used serum samples from patients with Group I PAH and plasma and tissue samples derived from the Sugen/hypoxia rat pulmonary hypertension model to define associations between COL18A1/ES and disease development, including hemodynamics, right ventricle (RV) remodeling, and RV dysfunction. Using cardiac magnetic resonance imaging and advanced hemodynamic assessments with pressure-volume loops in patients with PAH to assess RV-pulmonary arterial coupling, we observed a strong relationship between circulating ES levels and metrics of RV structure and function. Specifically, RV mass and the ventricular mass index were positively associated with ES, whereas RV ejection fraction and RV-pulmonary arterial coupling were inversely associated with ES levels. Our animal data demonstrate that the development of pulmonary hypertension is associated with increased COL18A1/ES in the heart as well as the lungs. Disease-associated increases in COL18A1 mRNA and protein were most pronounced in the RV compared with the left ventricle and lung. COL18A1 expression in the RV was strongly associated with disease-associated changes in RV mass, fibrosis, and myocardial capillary density. These findings indicate that COL18A1/ES increases early in disease development in the RV and implicates COL18A1/ES in pathologic RV dysfunction in PAH.
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Affiliation(s)
| | - Mario Naranjo
- Department of Thoracic Medicine and Surgery, Temple University, Philadelphia, Pennsylvania
| | - Tijana Tuhy
- Division of Pulmonary and Critical Care Medicine
| | - Rose Yu
- Division of Pulmonary Medicine, Johns Hopkins Community Physicians, Columbia, Maryland
| | - Mery Marimoutou
- Institute for In Vitro Sciences, Gaithersburg, Maryland; and
| | | | | | | | | | | | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Steven Hsu
- Division of Cardiology, Department of Medicine
| | | | - Rachel L Damico
- Division of Pulmonary and Critical Care Medicine
- Environmental Health Sciences, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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2
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Kwan ED, Hardie BA, Garcia KM, Mu H, Wang TM, Valdez-Jasso D. Sex-dependent remodeling of right ventricular function in a rat model of pulmonary arterial hypertension. Am J Physiol Heart Circ Physiol 2024; 327:H351-H363. [PMID: 38847755 DOI: 10.1152/ajpheart.00098.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/09/2024] [Accepted: 05/29/2024] [Indexed: 07/17/2024]
Abstract
Right ventricular (RV) function is an important prognostic indicator for pulmonary arterial hypertension (PAH), a vasculopathy that primarily and disproportionally affects women with distinct pre- and postmenopausal clinical outcomes. However, most animal studies have overlooked the impact of sex and ovarian hormones on RV remodeling in PAH. Here, we combined invasive measurements of RV hemodynamics and morphology with computational models of RV biomechanics in sugen-hypoxia (SuHx)-treated male, ovary-intact female, and ovariectomized female rats. Despite similar pressure overload levels, SuHx induced increases in end-diastolic elastance and passive myocardial stiffening, notably in male SuHx animals, corresponding to elevated diastolic intracellular calcium. Increases in end-systolic chamber elastance were largely explained by myocardial hypertrophy in male and ovary-intact female rats, whereas ovariectomized females exhibited contractility recruitment via calcium transient augmentation. Ovary-intact female rats primarily responded with hypertrophy, showing fewer myocardial mechanical alterations and less stiffening. These findings highlight sex-related RV remodeling differences in rats, affecting systolic and diastolic RV function in PAH.NEW & NOTEWORTHY Combining hemodynamic and morphological measurements from male, female, and ovariectomized female pulmonary arterial hypertension (PAH) rats revealed distinct adaptation mechanisms despite similar pressure overload. Males showed the most diastolic stiffening. Ovariectomized females had enhanced myocyte contractility and calcium transient upregulation. Ovary-intact females primarily responded with hypertrophy, experiencing milder passive myocardial stiffening and no changes in myocyte shortening. These findings suggest potential sex-specific pathways in right ventricular (RV) adaptation to PAH, with implications for targeted interventions.
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MESH Headings
- Animals
- Female
- Male
- Ventricular Function, Right
- Ventricular Remodeling
- Disease Models, Animal
- Rats, Sprague-Dawley
- Ovariectomy
- Pulmonary Arterial Hypertension/physiopathology
- Pulmonary Arterial Hypertension/metabolism
- Pulmonary Arterial Hypertension/etiology
- Sex Factors
- Hypertrophy, Right Ventricular/physiopathology
- Hypertrophy, Right Ventricular/etiology
- Hypertrophy, Right Ventricular/metabolism
- Hypertrophy, Right Ventricular/pathology
- Rats
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Dysfunction, Right/metabolism
- Ventricular Dysfunction, Right/etiology
- Pulmonary Artery/physiopathology
- Pulmonary Artery/metabolism
- Pulmonary Artery/pathology
- Models, Cardiovascular
- Calcium Signaling
- Hypertension, Pulmonary/physiopathology
- Hypertension, Pulmonary/metabolism
- Hypertension, Pulmonary/etiology
- Hemodynamics
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Affiliation(s)
- Ethan D Kwan
- Shu Chien-Gene Ley Department of BioengineeringUniversity of California, San Diego, La Jolla, California, United States
| | - Becky A Hardie
- Shu Chien-Gene Ley Department of BioengineeringUniversity of California, San Diego, La Jolla, California, United States
| | - Kristen M Garcia
- Shu Chien-Gene Ley Department of BioengineeringUniversity of California, San Diego, La Jolla, California, United States
| | - Hao Mu
- Shu Chien-Gene Ley Department of BioengineeringUniversity of California, San Diego, La Jolla, California, United States
| | - Tsui-Min Wang
- Shu Chien-Gene Ley Department of BioengineeringUniversity of California, San Diego, La Jolla, California, United States
| | - Daniela Valdez-Jasso
- Shu Chien-Gene Ley Department of BioengineeringUniversity of California, San Diego, La Jolla, California, United States
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Liu Q, Luo Q, Zhong B, Xiong Y, Chen X, Li X. Preparation of the new peptide drug ACTY116-loaded in situ forming implants and evaluation of its efficacy in pulmonary arterial hypertension and right ventricular hypertrophy induced by SU5416/hypoxia in mice. Basic Clin Pharmacol Toxicol 2024; 135:60-70. [PMID: 38767191 DOI: 10.1111/bcpt.14020] [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: 11/22/2023] [Revised: 04/29/2024] [Accepted: 05/03/2024] [Indexed: 05/22/2024]
Abstract
There is a lack of effective therapeutic drugs for pulmonary arterial hypertension. Previous studies have demonstrated the positive cardiovascular system protective effects of the new peptide ACTY116. However, its stability in ordinary aqueous solution injections is poor and its half-life in the body is short, which has hindered the development of preparations. This study aimed to prepare in situ forming implants (ISFIs) of the peptide ACTY116 and investigate its impact on pulmonary arterial hypertension. We prepared ISFIs using NMP/TA as a solvent and PLGA as a polymer. These ISFIs exhibited low viscosity, low toxicity and sustained release properties. In a mouse model of pulmonary hypertension induced by SU5416/hypoxia, both ISFIs and ACTY116 peptides effectively reduced pulmonary hypertension, cardiac hypertrophy and pulmonary blood vessel wall thickness. In conclusion, this study highlights the potential of ACTY116 as a treatment for pulmonary arterial hypertension and suggests that incorporating it into an in-situ gel implant could be a promising option.
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Affiliation(s)
- Qiao Liu
- Institute of Materia Medica and Department of Pharmaceutics, Army Medical University, Chongqing, China
- Chongqing Medical and Pharmaceutical College, Chongqing, China
| | - Qingman Luo
- Institute of Materia Medica and Department of Pharmaceutics, Army Medical University, Chongqing, China
| | - Bin Zhong
- Institute of Materia Medica and Department of Pharmaceutics, Army Medical University, Chongqing, China
| | - Yingxin Xiong
- Institute of Materia Medica and Department of Pharmaceutics, Army Medical University, Chongqing, China
| | - Xueling Chen
- Chongqing School of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing, China
| | - Xiaohui Li
- Institute of Materia Medica and Department of Pharmaceutics, Army Medical University, Chongqing, China
- Chongqing Engineering Research Center for Pharmacodynamics Evaluation, College of Pharmacy, Army Medical University, Chongqing, China
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Patterson MT, Prins KW. An exercise in relaxation: right ventricular diastolic function predicts exercise capacity in pulmonary arterial hypertension. Eur Respir J 2024; 64:2401142. [PMID: 39025515 DOI: 10.1183/13993003.01142-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Accepted: 06/20/2024] [Indexed: 07/20/2024]
Affiliation(s)
| | - Kurt W Prins
- Lillehei Heart Institute, Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
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5
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Cubero Salazar IM, Lancaster AC, Jani VP, Montovano MJ, Kauffman M, Weller A, Ambale-Venkatesh B, Zimmerman SL, Simpson CE, Kolb TM, Damico RL, Mathai SC, Mukherjee M, Tedford RJ, Hassoun PM, Hsu S. Poor cardiac output reserve in pulmonary arterial hypertension is associated with right ventricular stiffness and impaired interventricular dependence. Eur Respir J 2024; 64:2400420. [PMID: 38843915 DOI: 10.1183/13993003.00420-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/19/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is characterised by poor exercise tolerance. The contribution of right ventricular (RV) diastolic function to the augmentation of cardiac output during exercise is not known. This study leverages pressure-volume (P-V) loop analysis to characterise the impact of RV diastology on poor flow augmentation during exercise in PAH. METHODS RV P-V loops were measured in 41 PAH patients at rest and during supine bike exercise. Patients were stratified by median change in cardiac index (CI) during exercise into two groups: high and low CI reserve. Indices of diastolic function (end-diastolic elastance (E ed)) and ventricular interdependence (left ventricular transmural pressure (LVTMP)) were compared at matched exercise stages. RESULTS Compared to patients with high CI reserve, those with low reserve exhibited lower exercise stroke volume (36 versus 49 mL·m-2; p=0.0001), with higher associated exercise afterload (effective arterial elastance (E a) 1.76 versus 0.90 mmHg·mL-1; p<0.0001), RV stiffness (E ed 0.68 versus 0.26 mmHg·mL-1; p=0.003) and right-sided pressures (right atrial pressure 14 versus 8 mmHg; p=0.002). Higher right-sided pressures led to significantly lower LV filling among the low CI reserve subjects (LVTMP -4.6 versus 3.2 mmHg; p=0.0001). Interestingly, low exercise flow reserve correlated significantly with high afterload and RV stiffness, but not with RV contractility nor RV-PA coupling. CONCLUSIONS Patients with poor exercise CI reserve exhibit poor exercise RV afterload, stiffness and right-sided filling pressures that depress LV filling and stroke work. High afterload and RV stiffness were the best correlates to low flow reserve in PAH. Exercise unmasked significant pathophysiological PAH differences unapparent at rest.
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Affiliation(s)
| | - Andrew C Lancaster
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vivek P Jani
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Margaret J Montovano
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew Kauffman
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexandra Weller
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bharath Ambale-Venkatesh
- Division of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stefan L Zimmerman
- Division of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Catherine E Simpson
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Todd M Kolb
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Rachel L Damico
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Monica Mukherjee
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Steven Hsu
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Scheel PJ, Cubero Salazar IM, Friedman S, Haber L, Mukherjee M, Kauffman M, Weller A, Alkhunaizi F, Gilotra NA, Sharma K, Kilic A, Hassoun PM, Cornwell WK, Tedford RJ, Hsu S. Occult right ventricular dysfunction and right ventricular-vascular uncoupling in left ventricular assist device recipients. J Heart Lung Transplant 2024; 43:594-603. [PMID: 38036276 PMCID: PMC10947813 DOI: 10.1016/j.healun.2023.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 11/15/2023] [Accepted: 11/21/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Detecting right heart failure post left ventricular assist device (LVAD) is challenging. Sensitive pressure-volume loop assessments of right ventricle (RV) contractility may improve our appreciation of post-LVAD RV dysfunction. METHODS Thirteen LVAD patients and 20 reference (non-LVAD) subjects underwent comparison of echocardiographic, right heart cath hemodynamic, and pressure-volume loop-derived assessments of RV contractility using end-systolic elastance (Ees), RV afterload by effective arterial elastance (Ea), and RV-pulmonary arterial coupling (ratio of Ees/Ea). RESULTS LVAD patients had lower RV Ees (0.20 ± 0.08 vs 0.30 ± 0.15 mm Hg/ml, p = 0.01) and lower RV Ees/Ea (0.37 ± 0.14 vs 1.20 ± 0.54, p < 0.001) versus reference subjects. Low RV Ees correlated with reduced RV septal strain, an indicator of septal contractility, in both the entire cohort (r = 0.68, p = 0.004) as well as the LVAD cohort itself (r = 0.78, p = 0.02). LVAD recipients with low RV Ees/Ea (below the median value) demonstrated more clinical heart failure (71% vs 17%, p = 0.048), driven by an inability to augment RV Ees (0.22 ± 0.11 vs 0.19 ± 0.02 mm Hg/ml, p = 0.95) to accommodate higher RV Ea (0.82 ± 0.38 vs 0.39 ± 0.08 mm Hg/ml, p = 0.002). Pulmonary artery pulsatility index (PAPi) best identified low baseline RV Ees/Ea (≤0.35) in LVAD patients ((area under the curve) AUC = 0.80); during the ramp study, change in PAPi also correlated with change in RV Ees/Ea (r = 0.58, p = 0.04). CONCLUSIONS LVAD patients demonstrate occult intrinsic RV dysfunction. In the setting of excess RV afterload, LVAD patients lack the RV contractile reserve to maintain ventriculo-vascular coupling. Depression in RV contractility may be related to LVAD left ventricular unloading, which reduces septal contractility.
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Affiliation(s)
- Paul J Scheel
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ilton M Cubero Salazar
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Samuel Friedman
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Leora Haber
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Monica Mukherjee
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew Kauffman
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexandra Weller
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Fatimah Alkhunaizi
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nisha A Gilotra
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kavita Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmet Kilic
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Paul M Hassoun
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - William K Cornwell
- Division of Cardiology, Department of Medicine, University of Anschutz Medical Campus, Aurora, Colorado; Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Forbes LM, Bull TM, Lahm T, Sisson T, O’Gean K, Lawley JS, Hunter K, Levine BD, Lovering A, Roach RC, Subudhi AW, Cornwell WK. Right ventricular performance during acute hypoxic exercise. J Physiol 2024:10.1113/JP284943. [PMID: 38409819 PMCID: PMC11345882 DOI: 10.1113/jp284943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 02/01/2024] [Indexed: 02/28/2024] Open
Abstract
Acute hypoxia increases pulmonary arterial (PA) pressures, though its effect on right ventricular (RV) function is controversial. The objective of this study was to characterize exertional RV performance during acute hypoxia. Ten healthy participants (34 ± 10 years, 7 males) completed three visits: visits 1 and 2 included non-invasive normoxic (fraction of inspired oxygen (F i O 2 ${F_{{\mathrm{i}}{{\mathrm{O}}_{\mathrm{2}}}}}$ ) = 0.21) and isobaric hypoxic (F i O 2 ${F_{{\mathrm{i}}{{\mathrm{O}}_{\mathrm{2}}}}}$ = 0.12) cardiopulmonary exercise testing (CPET) to determine normoxic/hypoxic maximal oxygen uptake (V ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ ). Visit 3 involved invasive haemodynamic assessments where participants were randomized 1:1 to either Swan-Ganz or conductance catheterization to quantify RV performance via pressure-volume analysis. Arterial oxygen saturation was determined by blood gas analysis from radial arterial catheterization. During visit 3, participants completed invasive submaximal CPET testing at 50% normoxicV ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ and again at 50% hypoxicV ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ (F i O 2 ${F_{{\mathrm{i}}{{\mathrm{O}}_{\mathrm{2}}}}}$ = 0.12). Median (interquartile range) values for non-invasiveV ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ values during normoxic and hypoxic testing were 2.98 (2.43, 3.66) l/min and 1.84 (1.62, 2.25) l/min, respectively (P < 0.0001). Mean PA pressure increased significantly when transitioning from rest to submaximal exercise during normoxic and hypoxic conditions (P = 0.0014). Metrics of RV contractility including preload recruitable stroke work, dP/dtmax , and end-systolic pressure increased significantly during the transition from rest to exercise under normoxic and hypoxic conditions. Ventricular-arterial coupling was maintained during normoxic exercise at 50%V ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ . During submaximal exercise at 50% of hypoxicV ̇ O 2 max ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ , ventricular-arterial coupling declined but remained within normal limits. In conclusion, resting and exertional RV functions are preserved in response to acute exposure to hypoxia at anF i O 2 ${F_{{\mathrm{i}}{{\mathrm{O}}_{\mathrm{2}}}}}$ = 0.12 and the associated increase in PA pressures. KEY POINTS: The healthy right ventricle augments contractility, lusitropy and energetics during periods of increased metabolic demand (e.g. exercise) in acute hypoxic conditions. During submaximal exercise, ventricular-arterial coupling decreases but remains within normal limits, ensuring that cardiac output and systemic perfusion are maintained. These data describe right ventricular physiological responses during submaximal exercise under conditions of acute hypoxia, such as occurs during exposure to high altitude and/or acute hypoxic respiratory failure.
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Affiliation(s)
- Lindsay M. Forbes
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado, United States
| | - Todd M. Bull
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado, United States
| | - Tim Lahm
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado, United States
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado, United States
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, United States
| | - Tyler Sisson
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora CO
| | - Katie O’Gean
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora CO
| | - Justin S. Lawley
- Department of Sport Science, University of Innsbruck, Innsbruck Austria
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Kendall Hunter
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora CO
| | - Benjamin D. Levine
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
- Texas Health Presbyterian Hospital, Institute for Exercise and Environmental Medicine, Dallas TX
| | | | - Robert C. Roach
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, Colorado, United States
| | - Andrew W. Subudhi
- Department of Physiology, University of Colorado, Colorado Springs, Colorado, United States
| | - William K. Cornwell
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora CO
- Division of Cardiology, Department of Medicine. University of Colorado, Aurora, Colorado, United States
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Corona LFV, Reyna TSR. Right Ventricle and Autoimmune Diseases. Curr Rheumatol Rev 2024; 20:127-132. [PMID: 37861019 DOI: 10.2174/0115733971262676230920102922] [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: 06/02/2023] [Revised: 08/09/2023] [Accepted: 08/21/2023] [Indexed: 10/21/2023]
Abstract
Autoimmune diseases can express pathologies in specific organs (e.g. thyroid, pancreas, skin) or generate systemic pathologies (generalized lupus erythematosus, rheumatoid arthritis, systemic sclerosis), the latter usually present systemic inflammatory phenomena. Some studies have reported alterations in right ventricular contractility in patients with rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, and juvenile idiopathic arthritis, which may contribute to the known outcome of increased cardiovascular risk. However, there is not much information available on the causes that generate these alterations, the most likely being small vessel damage and fibrosis due to subclinical inflammation.1-5 In this sense, the disease in which the alterations of the right ventricle have been more studied is systemic sclerosis, specifically at the changes induced due to pulmonary arterial hypertension, this being one of the main causes of death in this group of patients after the significant decrease in mortality associated with the sclerodermic renal crisis with the treatment of angiotensin-converting enzyme inhibitors. In this review, we will focus on explaining the structural and functional changes that occur in the right ventricle of patients with systemic sclerosis, from early alterations to late complications. In this context, it is necessary to distinguish between right heart alterations that occur in patients with systemic sclerosis and pulmonary arterial hypertension and those that occur without pulmonary arterial hypertension and that can be attributed to other causes such as microvascular damage or myocardial fibrosis.
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El Shaer A, Garcia-Arango M, Korcarz C, Broman AT, Lechuga CG, Chesler NC, Raza F. Right ventricular outflow tract diameter change with exercise: a prospective exercise echocardiography and invasive CPET study. EUROPEAN HEART JOURNAL. IMAGING METHODS AND PRACTICE 2024; 2:qyae039. [PMID: 38784433 PMCID: PMC11109549 DOI: 10.1093/ehjimp/qyae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/01/2024] [Indexed: 05/25/2024]
Abstract
While cardiac output reserve with exercise predicts outcomes in cardiac and pulmonary vascular disease, precise quantification of exercise cardiac output requires invasive cardiopulmonary testing (iCPET). To improve the accuracy of cardiac output reserve estimation with transthoracic echocardiography (TTE), this prospective study aims to define changes in right ventricular outflow tract diameter (RVOTd) with exercise and its relationship with invasively measured haemodynamics. Twenty subjects underwent simultaneous TTE and iCPET, with data collected at rest, leg-raise, 25 W, 50 W (n = 16), 75 W (n = 14), and 100 W (n = 6). This was followed by a second exercise study with real-time RV pressure-volume loops at similar stages (except leg-raise). The overall cohort included heart failure with preserved ejection fraction (n = 12), pulmonary arterial hypertension (n = 5), and non-cardiac dyspnoea (n = 3). RVOTd was reverse engineered from the TTE-derived RVOT velocity time integral (VTI) and iCPET-derived stroke volume, using the formula: Fick stroke volume = RVOT VTI × RVOT area (wherein RVOT area = π × [RVOTd/2]2). RVOTd increased by nearly 3-4% at every 25 W increment. Using linear regression models, where each subject is treated as a categorical variable and adjusting for subject intercept, RVOTd was correlated with haemodynamic variables (cardiac output, heart rate, pulmonary artery and RV pressures). Of all the predictor haemodynamic variables, cardiac output had the highest r2 model fit (adjusted r2 = 0.68), with a unit increase in cardiac output associated with a 0.0678 increase in RVOTd (P < 0.001). Our findings indicate that RVOTd increases by 3-4% with every 25 W increment, predominantly correlated with cardiac output augmentation. These results can improve the accuracy of cardiac output reserve estimation by adjusting for RVOTd with graded exercise during non-invasive CPET and echocardiogram. However, future studies are needed to define these relationships for left ventricular outflow tract diameter.
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Affiliation(s)
- Ahmed El Shaer
- Department of Internal Medicine, University of Wisconsin Hospital, 600 Highland Avenue, Madison, WI 53792, USA
| | - Mariana Garcia-Arango
- Department of Internal Medicine, University of Wisconsin Hospital, 600 Highland Avenue, Madison, WI 53792, USA
| | - Claudia Korcarz
- Department of Cardiovascular Medicine, University of Wisconsin Hospital, 600 Highland Avenue, Madison, WI 53792, USA
| | - Aimee Teo Broman
- Department of Biostatistics and Medical Informatics, University of Wisconsin Hospital, Madison, WI, USA
| | - Christopher G Lechuga
- Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center (CIRC) and Department of Biomedical Engineering, University of California, Irvine, CA, USA
| | - Naomi C Chesler
- Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center (CIRC) and Department of Biomedical Engineering, University of California, Irvine, CA, USA
| | - Farhan Raza
- Department of Internal Medicine, University of Wisconsin Hospital, 600 Highland Avenue, Madison, WI 53792, USA
- Department of Cardiovascular Medicine, University of Wisconsin Hospital, 600 Highland Avenue, Madison, WI 53792, USA
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Häfner F, Kindt A, Strobl K, Förster K, Heydarian M, Gonzalez E, Schubert B, Kraus Y, Dalla Pozza R, Flemmer AW, Ertl-Wagner B, Dietrich O, Stoecklein S, Tello K, Hilgendorff A. MRI pulmonary artery flow detects lung vascular pathology in preterms with lung disease. Eur Respir J 2023; 62:2202445. [PMID: 37678954 PMCID: PMC10749508 DOI: 10.1183/13993003.02445-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 07/24/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Pulmonary vascular disease (PVD) affects the majority of preterm neonates with bronchopulmonary dysplasia (BPD) and significantly determines long-term mortality through undetected progression into pulmonary hypertension. Our objectives were to associate characteristics of pulmonary artery (PA) flow and cardiac function with BPD-associated PVD near term using advanced magnetic resonance imaging (MRI) for improved risk stratification. METHODS Preterms <32 weeks postmenstrual age (PMA) with/without BPD were clinically monitored including standard echocardiography and prospectively enrolled for 3 T MRI in spontaneous sleep near term (AIRR (Attention to Infants at Respiratory Risks) study). Semi-manual PA flow quantification (phase-contrast MRI; no BPD n=28, mild BPD n=35 and moderate/severe BPD n=25) was complemented by cardiac function assessment (cine MRI). RESULTS We identified abnormalities in PA flow and cardiac function, i.e. increased net forward volume right/left ratio, decreased mean relative area change and pathological right end-diastolic volume, to sensitively detect BPD-associated PVD while correcting for PMA (leave-one-out area under the curve 0.88, sensitivity 0.80 and specificity 0.81). We linked these changes to increased right ventricular (RV) afterload (RV-arterial coupling (p=0.02), PA mid-systolic notching (t2; p=0.015) and cardiac index (p=1.67×10-8)) and correlated echocardiographic findings. Identified in moderate/severe BPD, we successfully applied the PA flow model in heterogeneous mild BPD cases, demonstrating strong correlation of PVD probability with indicators of BPD severity, i.e. duration of mechanical ventilation (rs=0.63, p=2.20×10-4) and oxygen supplementation (rs=0.60, p=6.00×10-4). CONCLUSIONS Abnormalities in MRI PA flow and cardiac function exhibit significant, synergistic potential to detect BPD-associated PVD, advancing the possibilities of risk-adapted monitoring.
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Affiliation(s)
- Friederike Häfner
- Institute for Lung Health and Immunity and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Center Munich, Member of the German Center for Lung Research (DZL), Munich, Germany
- Center for Comprehensive Developmental Care (CDeCLMU) at the interdisciplinary Social Pediatric Center (iSPZ Hauner), Haunersches Children's Hospital, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
- F. Häfner and A. Kindt contributed equally to this study
| | - Alida Kindt
- Metabolomics and Analytics Centre, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
- F. Häfner and A. Kindt contributed equally to this study
| | - Kathrin Strobl
- Center for Comprehensive Developmental Care (CDeCLMU) at the interdisciplinary Social Pediatric Center (iSPZ Hauner), Haunersches Children's Hospital, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Kai Förster
- Center for Comprehensive Developmental Care (CDeCLMU) at the interdisciplinary Social Pediatric Center (iSPZ Hauner), Haunersches Children's Hospital, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
- Division of Neonatology, University Children's Hospital Dr v. Hauner and Perinatal Center, University Hospital, Ludwig Maximilian University Munich, Munich Germany
| | - Motaharehsadat Heydarian
- Institute for Lung Health and Immunity and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Center Munich, Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Erika Gonzalez
- Institute for Lung Health and Immunity and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Center Munich, Member of the German Center for Lung Research (DZL), Munich, Germany
- Center for Comprehensive Developmental Care (CDeCLMU) at the interdisciplinary Social Pediatric Center (iSPZ Hauner), Haunersches Children's Hospital, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Benjamin Schubert
- Institute of Computational Biology, Helmholtz Center Munich, Munich, Germany
| | - Yvonne Kraus
- Center for Comprehensive Developmental Care (CDeCLMU) at the interdisciplinary Social Pediatric Center (iSPZ Hauner), Haunersches Children's Hospital, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Robert Dalla Pozza
- Department of Pediatric Cardiology, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Andreas W Flemmer
- Division of Neonatology, University Children's Hospital Dr v. Hauner and Perinatal Center, University Hospital, Ludwig Maximilian University Munich, Munich Germany
| | - Birgit Ertl-Wagner
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, ON, Canada
| | - Olaf Dietrich
- Department of Radiology, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Sophia Stoecklein
- Department of Radiology, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Khodr Tello
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Anne Hilgendorff
- Institute for Lung Health and Immunity and Comprehensive Pneumology Center with the CPC-M bioArchive, Helmholtz Center Munich, Member of the German Center for Lung Research (DZL), Munich, Germany
- Center for Comprehensive Developmental Care (CDeCLMU) at the interdisciplinary Social Pediatric Center (iSPZ Hauner), Haunersches Children's Hospital, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
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11
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Simpson CE, Hemnes AR, Griffiths M, Grunig G, Wilson Tang W, Garcia JGN, Barnard J, Comhair SA, Damico RL, Mathai SC, Hassoun PM. Metabolomic Differences in Connective Tissue Disease-Associated Versus Idiopathic Pulmonary Arterial Hypertension in the PVDOMICS Cohort. Arthritis Rheumatol 2023; 75:2240-2251. [PMID: 37335853 PMCID: PMC10728345 DOI: 10.1002/art.42632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVE Patients with connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) experience worse survival and derive less benefit from pulmonary vasodilator therapies than patients with idiopathic PAH (IPAH). We sought to identify differential metabolism in patients with CTD-PAH versus patients with IPAH that might underlie these observed clinical differences. METHODS Adult participants with CTD-PAH (n = 141) and IPAH (n = 165) from the Pulmonary Vascular Disease Phenomics (PVDOMICS) study were included. Detailed clinical phenotyping was performed at cohort enrollment, including broad-based global metabolomic profiling of plasma samples. Participants were followed prospectively for ascertainment of outcomes. Supervised and unsupervised machine learning algorithms and regression models were used to compare CTD-PAH versus IPAH metabolomic profiles and to measure metabolite-phenotype associations and interactions. Gradients across the pulmonary circulation were assessed using paired mixed venous and wedged samples in a subset of 115 participants. RESULTS Metabolomic profiles distinguished CTD-PAH from IPAH, with patients with CTD-PAH demonstrating aberrant lipid metabolism with lower circulating levels of sex steroid hormones and higher free fatty acids (FAs) and FA intermediates. Acylcholines were taken up by the right ventricular-pulmonary vascular (RV-PV) circulation, particularly in CTD-PAH, while free FAs and acylcarnitines were released. In both PAH subtypes, dysregulated lipid metabolites, among others, were associated with hemodynamic and RV measurements and with transplant-free survival. CONCLUSIONS CTD-PAH is characterized by aberrant lipid metabolism that may signal shifted metabolic substrate utilization. Abnormalities in RV-PV FA metabolism may imply a reduced capacity for mitochondrial beta oxidation within the diseased pulmonary circulation.
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Affiliation(s)
| | - Anna R. Hemnes
- Vanderbilt University Division of Allergy, Pulmonary, and Critical Care Medicine
| | - Megan Griffiths
- University of Texas Southwestern Medical Center, Division of Pediatric Cardiology
| | - Gabriele Grunig
- Divisions of Environmental and Pulmonary Medicine, Department of Medicine, NYU Grossman School of Medicine
| | - W.H. Wilson Tang
- Cleveland Clinic Department of Cardiovascular Medicine, Section of Heart Failure and Transplant Medicine
| | - Joe G. N. Garcia
- University of Arizona College of Medicine – Tucson, Department of Medicine
| | | | | | - Rachel L. Damico
- Johns Hopkins University Division of Pulmonary and Critical Care Medicine
| | - Stephen C. Mathai
- Johns Hopkins University Division of Pulmonary and Critical Care Medicine
| | - Paul M. Hassoun
- Johns Hopkins University Division of Pulmonary and Critical Care Medicine
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12
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de Barros JA, Sant'Ana G, Martins G, Madlum L, Scremim C, Petterle R, Escuissato D, Lima E. Severity of precapillary pulmonary hypertension: Predictive factor. Pulmonology 2023; 29 Suppl 4:S25-S35. [PMID: 34969648 DOI: 10.1016/j.pulmoe.2021.11.007] [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: 04/16/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with pulmonary arterial hypertension (PAH) require risk assessments for prognosis and appropriate therapy. These assessments need to be improved by incorporating clinical and laboratory data such as the analysis of the right ventricle. We aim to establish echocardiographic morphometric data of the right ventricle and its relationship with the left ventricle, to estimate the hemodynamic severity of precapillary pulmonary hypertension (PHprecapillary). METHODS This cohort, prospective, observational, and cross-sectional study included 41 consecutive patients with PHprecapillary using echocardiographic study and cardiac catheterization. RESULTS Patients' mean age was 44.0±16.4 years, and 37 were women (90.2%). Idiopathic PAH was diagnosed in 18 patients (43.9%). The World Health Organization/New York Association functional class was III or IV in 31 patients (75.6%). The ratio of the right to left ventricles (RV/LV) echocardiographic diastolic diameters was associated with pulmonary arterial pressures in cardiac catheterization, with the best cutoff per receiver operating characteristic curve being 0.8 for systolic pressure (sensitivity 90.0%, specificity 78.3%, area under the curve [AUC] 0.882) and mean pressure (sensitivity 60.0%, specificity 95.7%, AUC 0.823). Spearman's correlation (R) of RV/LV echocardiographic ratio and the hemodynamic variables was significant for systolic pressure (R = 0.7015, p < 0.0001), mean pressure (R = 0.6332, p < 0.0001), transpulmonary pressure gradient (R = 0.6524, p < 0.0001), pulmonary vascular resistance (R = 0.6076, p = 0.0021), and pulmonary vascular resistance index (R = 0.6229, p = 0.0014). CONCLUSION The ratio of RV/LV echocardiographic diastolic diameters contribute to the estimates the hemodynamic severity of precapillary pulmonary hypertension. The best cutoff for this assessment was RV/LV of 0.8.
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Affiliation(s)
- J A de Barros
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil.
| | - G Sant'Ana
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
| | - G Martins
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
| | - L Madlum
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
| | - C Scremim
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
| | - R Petterle
- Federal University of Paraná, Department of Integrative Medicine, Curitiba, Brazil
| | - D Escuissato
- Federal University of Paraná, Department of Internal Medicine, Radiology Unit, Curitiba, Brazil
| | - E Lima
- Federal University of Paraná, Department of Internal Medicine, Cardiology and Pneumology Unit, Curitiba, Brazil
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13
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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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14
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Forbes LM, Bull TM, Lahm T, Make BJ, Cornwell WK. Exercise Testing in the Risk Assessment of Pulmonary Hypertension. Chest 2023; 164:736-746. [PMID: 37061028 PMCID: PMC10504600 DOI: 10.1016/j.chest.2023.04.013] [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: 12/12/2022] [Revised: 04/04/2023] [Accepted: 04/09/2023] [Indexed: 04/17/2023] Open
Abstract
TOPIC IMPORTANCE Right ventricular dysfunction in pulmonary hypertension (PH) contributes to reduced exercise capacity, morbidity, and mortality. Exercise can unmask right ventricular dysfunction not apparent at rest, with negative implications for prognosis. REVIEW FINDINGS Among patients with pulmonary vascular disease, right ventricular afterload may increase during exercise out of proportion to increases observed among healthy individuals. Right ventricular contractility must increase to match the demands of increased afterload to maintain ventricular-arterial coupling (the relationship between contractility and afterload) and ultimately cardiac output. Impaired right ventricular contractile reserve leads to ventricular-arterial uncoupling, preventing cardiac output from increasing during exercise and limiting exercise capacity. Abnormal pulmonary vascular response to exercise can signify early pulmonary vascular disease and is associated with increased mortality. Impaired right ventricular contractile reserve similarly predicts poor outcomes, including reduced exercise capacity and death. Exercise provocation can be used to assess pulmonary vascular response to exercise and right ventricular contractile reserve. Noninvasive techniques (including cardiopulmonary exercise testing, transthoracic echocardiography, and cardiac MRI) as well as invasive techniques (including right heart catheterization and pressure-volume analysis) may be applied selectively to the screening, diagnosis, and risk stratification of patients with suspected or established PH. Further research is required to determine the role of exercise stress testing in the management of pulmonary vascular disease. SUMMARY This review describes the current understanding of clinical applications of exercise testing in the risk assessment of patients with suspected or established PH.
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Affiliation(s)
- Lindsay M Forbes
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Todd M Bull
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Rocky Mountain Regional VA Medical Center, Aurora, Colorado; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
| | - Barry J Make
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
| | - William K Cornwell
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
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15
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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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16
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Jani V, Aslam MI, Fenwick AJ, Ma W, Gong H, Milburn G, Nissen D, Cubero Salazar IM, Hanselman O, Mukherjee M, Halushka MK, Margulies KB, Campbell KS, Irving TC, Kass DA, Hsu S. Right Ventricular Sarcomere Contractile Depression and the Role of Thick Filament Activation in Human Heart Failure With Pulmonary Hypertension. Circulation 2023; 147:1919-1932. [PMID: 37194598 PMCID: PMC10270283 DOI: 10.1161/circulationaha.123.064717] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 04/17/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Right ventricular (RV) contractile dysfunction commonly occurs and worsens outcomes in patients with heart failure with reduced ejection fraction and pulmonary hypertension (HFrEF-PH). However, such dysfunction often goes undetected by standard clinical RV indices, raising concerns that they may not reflect aspects of underlying myocyte dysfunction. We thus sought to characterize RV myocyte contractile depression in HFrEF-PH, identify those components reflected by clinical RV indices, and uncover underlying biophysical mechanisms. METHODS Resting, calcium-, and load-dependent mechanics were prospectively studied in permeabilized RV cardiomyocytes isolated from explanted hearts from 23 patients with HFrEF-PH undergoing cardiac transplantation and 9 organ donor controls. RESULTS Unsupervised machine learning using myocyte mechanical data with the highest variance yielded 2 HFrEF-PH subgroups that in turn mapped to patients with decompensated or compensated clinical RV function. This correspondence was driven by reduced calcium-activated isometric tension in decompensated clinical RV function, whereas surprisingly, many other major myocyte contractile measures including peak power and myocyte active stiffness were similarly depressed in both groups. Similar results were obtained when subgroups were first defined by clinical indices, and then myocyte mechanical properties in each group compared. To test the role of thick filament defects, myofibrillar structure was assessed by x-ray diffraction of muscle fibers. This revealed more myosin heads associated with the thick filament backbone in decompensated clinical RV function, but not compensated clinical RV function, as compared with controls. This corresponded to reduced myosin ATP turnover in decompensated clinical RV function myocytes, indicating less myosin in a crossbridge-ready disordered-relaxed (DRX) state. Altering DRX proportion (%DRX) affected peak calcium-activated tension in the patient groups differently, depending on their basal %DRX, highlighting potential roles for precision-guided therapeutics. Last, increasing myocyte preload (sarcomere length) increased %DRX 1.5-fold in controls but only 1.2-fold in both HFrEF-PH groups, revealing a novel mechanism for reduced myocyte active stiffness and by extension Frank-Starling reserve in human heart failure. CONCLUSIONS Although there are many RV myocyte contractile deficits in HFrEF-PH, commonly used clinical indices only detect reduced isometric calcium-stimulated force, which is related to deficits in basal and recruitable %DRX myosin. Our results support use of therapies to increase %DRX and enhance length-dependent recruitment of DRX myosin heads in such patients.
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Affiliation(s)
- Vivek Jani
- Department of Biomedical Engineering (V.J., O.H., D.A.K.), Johns Hopkins School of Medicine, Baltimore, MD
- Division of Cardiology, Department of Medicine (V.J., A.J.F., I.M.C.S., M.M., D.A.K., S.H.), Johns Hopkins School of Medicine, Baltimore, MD
| | - M. Imran Aslam
- Division of Cardiology, Department of Medicine, University of Texas San Antonio School of Medicine (M.I.A.)
| | - Axel J. Fenwick
- Division of Cardiology, Department of Medicine (V.J., A.J.F., I.M.C.S., M.M., D.A.K., S.H.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Weikang Ma
- Biophysics Collaborative Access Team (BioCAT), Department of Biology, Illinois Institute of Technology, Chicago (W.M., H.G., D.N., T.C.I.)
| | - Henry Gong
- Biophysics Collaborative Access Team (BioCAT), Department of Biology, Illinois Institute of Technology, Chicago (W.M., H.G., D.N., T.C.I.)
| | - Gregory Milburn
- Division of Cardiovascular Medicine, Department of Medicine, University of Kentucky, Lexington (G.M., K.S.C.)
| | - Devin Nissen
- Biophysics Collaborative Access Team (BioCAT), Department of Biology, Illinois Institute of Technology, Chicago (W.M., H.G., D.N., T.C.I.)
| | - Ilton M. Cubero Salazar
- Division of Cardiology, Department of Medicine (V.J., A.J.F., I.M.C.S., M.M., D.A.K., S.H.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Olivia Hanselman
- Department of Biomedical Engineering (V.J., O.H., D.A.K.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Monica Mukherjee
- Division of Cardiology, Department of Medicine (V.J., A.J.F., I.M.C.S., M.M., D.A.K., S.H.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Marc K. Halushka
- Division of Cardiovascular Pathology, Department of Pathology (M.K.H.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Kenneth B. Margulies
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia (K.B.M.)
| | - Kenneth S. Campbell
- Division of Cardiovascular Medicine, Department of Medicine, University of Kentucky, Lexington (G.M., K.S.C.)
| | - Thomas C. Irving
- Biophysics Collaborative Access Team (BioCAT), Department of Biology, Illinois Institute of Technology, Chicago (W.M., H.G., D.N., T.C.I.)
| | - David A. Kass
- Department of Biomedical Engineering (V.J., O.H., D.A.K.), Johns Hopkins School of Medicine, Baltimore, MD
- Division of Cardiology, Department of Medicine (V.J., A.J.F., I.M.C.S., M.M., D.A.K., S.H.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Steven Hsu
- Division of Cardiology, Department of Medicine (V.J., A.J.F., I.M.C.S., M.M., D.A.K., S.H.), Johns Hopkins School of Medicine, Baltimore, MD
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Škafar M, Ambrožič J, Toplišek J, Cvijić M. Role of Exercise Stress Echocardiography in Pulmonary Hypertension. Life (Basel) 2023; 13:1385. [PMID: 37374168 PMCID: PMC10302645 DOI: 10.3390/life13061385] [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: 05/01/2023] [Revised: 05/31/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
Resting and exercise right heart catheterisation is the gold standard method to diagnose and differentiate types of pulmonary hypertension (PH). As it carries technical challenges, the question arises if non-invasive exercise stress echocardiography may be used as an alternative. Exercise echocardiography can unmask exercise PH, detect the early stages of left ventricular diastolic dysfunction, and, therefore, differentiate between pre- and post-capillary PH. Regardless of the underlying aetiology, a developed PH is associated with increased mortality. Parameters of overt right ventricle (RV) dysfunction, including RV dilation, reduced RV ejection fraction, and elevated right-sided filling pressures, are detectable with resting echocardiography and are associated with worse outcome. However, these measures all fail to identify occult RV dysfunction. Echocardiographic measures of RV contractile reserve during exercise echocardiography are very promising and provide incremental prognostic information on clinical outcome. In this paper, we review pulmonary haemodynamic response to exercise, briefly describe the modalities for assessing pulmonary haemodynamics, and discuss in depth the contemporary key clinical application of exercise stress echocardiography in patients with PH.
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Affiliation(s)
- Mojca Škafar
- Department of Cardiology, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia; (M.Š.); (J.A.); (J.T.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
| | - Jana Ambrožič
- Department of Cardiology, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia; (M.Š.); (J.A.); (J.T.)
| | - Janez Toplišek
- Department of Cardiology, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia; (M.Š.); (J.A.); (J.T.)
| | - Marta Cvijić
- Department of Cardiology, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia; (M.Š.); (J.A.); (J.T.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
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Simpson CE, Coursen J, Hsu S, Gough EK, Harlan R, Roux A, Aja S, Graham D, Kauffman M, Suresh K, Tedford RJ, Kolb TM, Mathai SC, Hassoun PM, Damico RL. Metabolic profiling of in vivo right ventricular function and exercise performance in pulmonary arterial hypertension. Am J Physiol Lung Cell Mol Physiol 2023; 324:L836-L848. [PMID: 37070742 PMCID: PMC10228670 DOI: 10.1152/ajplung.00003.2023] [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: 01/03/2023] [Revised: 03/15/2023] [Accepted: 04/07/2023] [Indexed: 04/19/2023] Open
Abstract
Right ventricular (RV) adaptation is the principal determinant of outcomes in pulmonary arterial hypertension (PAH), however, RV function is challenging to assess. RV responses to hemodynamic stressors are particularly difficult to interrogate without invasive testing. This study sought to identify metabolomic markers of in vivo right ventricular function and exercise performance in PAH. Consecutive subjects with PAH (n = 23) underwent rest and exercise right heart catheterization with multibeat pressure volume loop analysis. Pulmonary arterial blood was collected at rest and during exercise. Mass spectrometry-based targeted metabolomics were performed, and metabolic associations with hemodynamics and comprehensive measures of RV function were determined using sparse partial least squares regression. Metabolite profiles were compared with N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) measurements for accuracy in modeling ventriculo-arterial parameters. Thirteen metabolites changed in abundance with exercise, including metabolites reflecting increased arginine bioavailability, precursors of catecholamine and nucleotide synthesis, and branched-chain amino acids. Higher resting arginine bioavailability predicted more favorable exercise hemodynamics and pressure-flow relationships. Subjects with more severe PAH augmented arginine bioavailability with exercise to a greater extent than subjects with less severe PAH. We identified relationships between kynurenine pathway metabolism and impaired ventriculo-arterial coupling, worse RV diastolic function, lower RV contractility, diminished RV contractility with exercise, and RV dilation with exercise. Metabolite profiles outperformed NT-proBNP in modeling RV contractility, diastolic function, and exercise performance. Specific metabolite profiles correspond to RV functional measurements only obtainable via invasive pressure-volume loop analysis and predict RV responses to exercise. Metabolic profiling may inform discovery of RV functional biomarkers.NEW & NOTEWORTHY In this cohort of patients with pulmonary arterial hypertension (PAH), we investigate metabolomic associations with comprehensive right ventricular (RV) functional measurements derived from multibeat RV pressure-volume loop analysis. Our results show that tryptophan metabolism, particularly the kynurenine pathway, is linked to intrinsic RV function and PAH pathobiology. Findings also highlight the importance of arginine bioavailability in the cardiopulmonary system's response to exercise stress. Metabolite profiles selected via unbiased analysis outperformed N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) in predicting load-independent measures of RV function at rest and cardiopulmonary system performance under stress. Overall, this work suggests the potential for select metabolites to function as disease-specific biomarkers, offers insights into PAH pathobiology, and informs discovery of potentially targetable RV-centric pathways.
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Affiliation(s)
- Catherine E Simpson
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Julie Coursen
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Steven Hsu
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Ethan K Gough
- Division of Human Nutrition, Johns Hopkins University School of Public Health, Baltimore, Maryland, United States
| | - Robert Harlan
- Molecular Determinants Core, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, United States
| | - Aurelie Roux
- Molecular Determinants Core, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, United States
| | - Susan Aja
- Molecular Determinants Core, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, United States
| | - David Graham
- Molecular Determinants Core, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, United States
| | - Matthew Kauffman
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Karthik Suresh
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Ryan J Tedford
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Todd M Kolb
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Rachel L Damico
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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He Q, Lin Y, Zhu Y, Gao L, Ji M, Zhang L, Xie M, Li Y. Clinical Usefulness of Right Ventricle-Pulmonary Artery Coupling in Cardiovascular Disease. J Clin Med 2023; 12:2526. [PMID: 37048609 PMCID: PMC10095537 DOI: 10.3390/jcm12072526] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/02/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Right ventricular-pulmonary artery coupling (RV-PA coupling) refers to the relationship between RV contractility and RV afterload. Normal RV-PA coupling is maintained only when RV function and pulmonary vascular resistance are appropriately matched. RV-PA uncoupling occurs when RV contractility cannot increase to match RV afterload, resulting in RV dysfunction and right heart failure. RV-PA coupling plays an important role in the pathophysiology and progression of cardiovascular diseases. Therefore, early and accurate evaluation of RV-PA coupling is of great significance for a patient's condition assessment, clinical decision making, risk stratification, and prognosis judgment. RV-PA coupling can be assessed by using invasive or noninvasive approaches. The aim of this review was to summarize the pathological mechanism and evaluation methods of RV-PA coupling, the advantages and disadvantages of each method, and the application value of RV-PA coupling in various cardiovascular diseases.
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Affiliation(s)
- Qing He
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Yixia Lin
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Ye Zhu
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Lang Gao
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Mengmeng Ji
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Li Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Mingxing Xie
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Yuman Li
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Clinical Research Center for Medical Imaging, Wuhan 430022, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
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Affiliation(s)
- Brian A Houston
- From the Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston (B.A.H., R.J.T.); and the Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville (E.L.B.)
| | - Evan L Brittain
- From the Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston (B.A.H., R.J.T.); and the Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville (E.L.B.)
| | - Ryan J Tedford
- From the Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston (B.A.H., R.J.T.); and the Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville (E.L.B.)
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21
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Lin Q, Kumar S, Kariyawasam U, Yang X, Yang W, Skinner JT, Gao WD, Johns RA. Human Resistin Induces Cardiac Dysfunction in Pulmonary Hypertension. J Am Heart Assoc 2023; 12:e027621. [PMID: 36927008 PMCID: PMC10111547 DOI: 10.1161/jaha.122.027621] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 03/18/2023]
Abstract
Background Cardiac failure is the primary cause of death in most patients with pulmonary arterial hypertension (PH). As pleiotropic cytokines, human resistin (Hresistin) and its rodent homolog, resistin-like molecule α, are mechanistically critical to pulmonary vascular remodeling in PH. However, it is still unclear whether activation of these resistin-like molecules can directly cause PH-associated cardiac dysfunction and remodeling. Methods and Results In this study, we detected Hresistin protein in right ventricular (RV) tissue of patients with PH and elevated resistin-like molecule expression in RV tissues of rodents with RV hypertrophy and failure. In a humanized mouse model, cardiac-specific Hresistin overexpression was sufficient to cause cardiac dysfunction and remodeling. Dilated hearts exhibited reduced force development and decreased intracellular Ca2+ transients. In the RV tissues overexpressing Hresistin, the impaired contractility was associated with the suppression of protein kinase A and AMP-activated protein kinase. Mechanistically, Hresistin activation triggered the inflammation mediated by signaling of the key damage-associated molecular pattern molecule high-mobility group box 1, and subsequently induced pro-proliferative Ki67 in RV tissues of the transgenic mice. Intriguingly, an anti-Hresistin human antibody that we generated protected the myocardium from hypertrophy and failure in the rodent PH models. Conclusions Our data indicate that Hresistin is expressed in heart tissues and plays a role in the development of RV dysfunction and maladaptive remodeling through its immunoregulatory activities. Targeting this signaling to modulate cardiac inflammation may offer a promising strategy to treat PH-associated RV hypertrophy and failure in humans.
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Affiliation(s)
- Qing Lin
- Department of Anesthesiology and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | - Santosh Kumar
- Department of Anesthesiology and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | - Udeshika Kariyawasam
- Department of Anesthesiology and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | - Xiaomei Yang
- Department of Anesthesiology and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreMD
- Department of AnesthesiologyQilu Hospital, Cheeloo College of Medicine, Shandong UniversityJinanChina
| | - Wei Yang
- Department of Anesthesiology and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreMD
- Department of Cardiovascular MedicineXiangya Hospital, Central South UniversityChangshaChina
| | - John T. Skinner
- Department of Anesthesiology and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | - Wei Dong Gao
- Department of Anesthesiology and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | - Roger A. Johns
- Department of Anesthesiology and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreMD
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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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Edward J, Banchs J, Parker H, Cornwell W. Right ventricular function across the spectrum of health and disease. Heart 2023; 109:349-355. [PMID: 35641176 PMCID: PMC9985748 DOI: 10.1136/heartjnl-2021-320526] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/27/2022] [Indexed: 11/04/2022] Open
Abstract
Knowledge of right ventricular (RV) structure and function has historically lagged behind that of the left ventricle (LV). However, advancements in invasive and non-invasive evaluations, combined with epidemiological analyses, have advanced the current understanding of RV (patho)physiology across the spectrum of health and disease, and reinforce the centrality of the RV in contributing to clinical outcomes. In the healthy heart, ventricular-arterial coupling is preserved during rest and in response to increased myocardial demand (eg, exercise) due to substantial RV contractile reserve. However, prolonged exposure to increased myocardial demand, such as endurance exercise, may precipitate RV dysfunction, suggesting that unlike the LV, the RV is unable to sustain high levels of contractility for extended periods of time. Emerging data increasingly indicate that both LV and RV function contribute to clinical heart failure. Reductions in quality-of-life, functional capacity and overall clinical outcomes are worsened among patients with heart failure when there is evidence of RV dysfunction. In addition, the RV is adversely impacted by pulmonary vascular disease, and among affected patients, overall RV function differs based on mechanisms of the underlying pulmonary hypertension, which may result from variations in sarcomere function within RV cardiomyocytes.
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Affiliation(s)
- Justin Edward
- Medicine-Cardiology, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jose Banchs
- Medicine-Cardiology, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Hugh Parker
- Medicine-Cardiology, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - William Cornwell
- Medicine-Cardiology, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
- Clinical Translational Research Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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24
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Zhu T, Wu P, Tan Z, Jin Q, Chen Y, Li L, Chen Z, Tang Y, Li J, Fang Z. Differences in right ventricular function and response to targeted therapy between patients with IPAH and PAH-CHD. Front Pharmacol 2023; 14:1124746. [PMID: 36860300 PMCID: PMC9968930 DOI: 10.3389/fphar.2023.1124746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/02/2023] [Indexed: 02/15/2023] Open
Abstract
Background and aims: Pulmonary arterial hypertension (PAH) is a chronic pulmonary vascular disorder characterized by elevated pulmonary vascular resistance (PVR) and pulmonary arterial pressure (PAP). Right heart failure is a life-threatening complication of PAH and predicts a poor prognosis. PAH associated with congenital heart disease (PAH-CHD) and idiopathic PAH (IPAH) are two prevalent PAH subtypes in China. In this section, we set out to explore baseline right ventricular (RV) function and its response to targeted agents between IPAH and PAH-CHD. Methods and results: Consecutive patients diagnosed with IPAH or PAH-CHD by right heart catheterization (RHC) in the Second Xiangya Hospital from November 2011 to June 2020 were included. All patients received PAH-targeted therapy and the RV function was assessed by echocardiography at baseline and during follow-up. A total of 303 patients (age, 36.23 ± 13.10 years; women, 213 (70.3%); mean PAP [mPAP], 63.54 ± 16.12 mmHg; PVR, 14.74 ± 7.61 WU) with IPAH (n = 121) or PAH-CHD (n = 182) were included in this study. Compared with PAH-CHD, patients with IPAH had worse baseline RV function. As of the latest follow-up, forty-nine patients with IPAH and six patients with PAH-CHD died. Kaplan-Meier analyses showed better survival in PAH-CHD versus IPAH. After PAH-targeted therapy, patients with IPAH had less improvement in 6 MWD, World Health Organization functional class, and RV functional parameters compared with patients with PAH-CHD. Conclusion: Compared with patients with PAH-CHD, patients with IPAH had worse baseline RV function, unfavourable prognosis, and inadequate response to targeted treatment.
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Affiliation(s)
- Tengteng Zhu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Panyun Wu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhen Tan
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Quan Jin
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yusi Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lian Li
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zewei Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yirui Tang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jiang Li
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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Zhou D, Li X, Yin G, Li S, Zhao S, Liu Z, Lu M. Risk Stratification and Outcomes in Patients With Pulmonary Hypertension: Insights into Right Ventricular Strain by MRI Feature tracking. J Magn Reson Imaging 2023; 57:545-556. [PMID: 35713378 DOI: 10.1002/jmri.28291] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Despite a recommended multidimensional approach for pulmonary hypertension (PH) risk stratification and guidance of treatment decisions, this may not always be achievable in patients with advanced disease. One issue is the lack of an imaging modality to assess right ventricular (RV) structure and function abnormalities. PURPOSE To explore the risk stratification and prognostic value of cardiac MR feature tracking (MR-FT)-derived RV strain. STUDY TYPE Retrospective. POPULATION A total of 80 patients with idiopathic pulmonary artery hypertension (N = 52) or chronic thromboembolic PH (N = 28). FIELD STRENGTH A 1.5 T or 3.0 T, balanced steady-state free precession sequence. ASSESSMENT All patients underwent laboratory testing, right heart catheterization, and MR imaging (and in 37 cases, a cardiopulmonary exercise test was also performed) within a 1-month period. Cardiac functional parameters and both global longitudinal strain (GLS) and global circumferential strain (GCS) were analyzed. Patients were stratified into low, intermediate, and high-risk groups by guideline suggested stratified values of risk factors. The combined endpoint was death or hospitalization for congestive heart failure assessed during follow-up since the date of MR examination. STATISTICAL TESTS Kolmogorov-Smirnov's test, independent-sample t-tests, Wilcoxon's rank-sum tests, one-way analysis of variance, χ2 tests or Fisher's exact test, receiver operating characteristic analysis, Kaplan-Meier survival analysis, and Cox regression analysis. A P value < 0.05 was considered statistically significant. RESULTS The median follow-up duration was 3.4 years. Thirty-five patients presented with combined endpoint including 10 cardiac deaths. RV structural and deformation impairments were significantly associated with combined endpoint (ejection fraction: 31.3% ± 13.2% vs. 38.0% ± 14.8%, hazard ratio [HR: 0.974; GLS: -14.5 [-18.6, -10.9] % vs. -20.4 [-26.0, -13.2] %, HR: 1.071; GCS: -9.8 [-14.5, -7.3] % vs. -12.3 [-19.9, -8.4] %, HR: 1.059). There were significant differences in RVGLS among low, intermediate, and high-risk groups (-19.3% ± 7.2% vs. -17.3% ± 9.4% vs. -11.5% ± 4.4% by cardiac functional class, -21.8% ± 7.3% vs. -19.4% ± 8.2% vs. -12.7 ± 5.3% by NT-proBNP, -19.7% ± 7.7 vs. -15.8% ± 6.5% vs. -12.6% ± 8.2% by cardiac index). DATA CONCLUSION RV deformation may aid risk stratification in patients with PH, providing crucial information for RV remodeling, pulmonary hemodynamic condition and exercise capacity. EVIDENCE LEVEL 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Di Zhou
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and 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 and Peking Union Medical College, Beijing, China
| | - Gang Yin
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuang Li
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shihua Zhao
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Minjie Lu
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese Academy of Medical Sciences, Beijing, China
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26
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Östenson B, Ostenfeld E, Edlund J, Heiberg E, Arheden H, Steding-Ehrenborg K. Endurance-trained subjects and sedentary controls increase ventricular contractility and efficiency during exercise: Feasibility of hemodynamics assessed by non-invasive pressure-volume loops. PLoS One 2023; 18:e0285592. [PMID: 37163493 PMCID: PMC10171617 DOI: 10.1371/journal.pone.0285592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 04/27/2023] [Indexed: 05/12/2023] Open
Abstract
INTRODUCTION Pressure-volume (PV) loops can be used to assess both load-dependent and load-independent measures of cardiac hemodynamics. However, analysis of PV loops during exercise is challenging as it requires invasive measures. Using a novel method, it has been shown that left ventricular (LV) PV loops at rest can be obtained non-invasively from cardiac magnetic resonance imaging (CMR) and brachial pressures. Therefore, the aim of this study was to assess if LV PV loops can be obtained non-invasively from CMR during exercise to assess cardiac hemodynamics. METHODS Thirteen endurance trained (ET; median 48 years [IQR 34-60]) and ten age and sex matched sedentary controls (SC; 43 years [27-57]) were included. CMR images were acquired at rest and during moderate intensity supine exercise defined as 60% of expected maximal heart rate. Brachial pressures were obtained in conjunction with image acquisition. RESULTS Contractility measured as maximal ventricular elastance (Emax) increased in both groups during exercise (ET: 1.0 mmHg/ml [0.9-1.1] to 1.1 mmHg/ml [0.9-1.2], p<0.01; SC: 1.1 mmHg/ml [0.9-1.2] to 1.2 mmHg/ml [1.0-1.3], p<0.01). Ventricular efficiency (VE) increased in ET from 70% [66-73] at rest to 78% [75-80] (p<0.01) during exercise and in SC from 68% [63-72] to 75% [73-78] (p<0.01). Arterial elastance (EA) decreased in both groups (ET: 0.8 mmHg/ml [0.7-0.9] to 0.7 mmHg/ml [0.7-0.9], p<0.05; SC: 1.0 mmHg/ml [0.9-1.2] to 0.9 mmHg/ml [0.8-1.0], p<0.05). Ventricular-arterial coupling (EA/Emax) also decreased in both groups (ET: 0.9 [0.8-1.0] to 0.7 [0.6-0.8], p<0.01; SC: 1.0 [0.9-1.1] to 0.7 [0.7-0.8], p<0.01). CONCLUSIONS This study demonstrates for the first time that LV PV loops can be generated non-invasively during exercise using CMR. ET and SC increase ventricular efficiency and contractility and decrease afterload and ventricular-arterial coupling during moderate supine exercise. These results confirm known physiology. Therefore, this novel method is applicable to be used during exercise in different cardiac disease states, which has not been possible non-invasively before.
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Affiliation(s)
- Björn Östenson
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Ellen Ostenfeld
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Jonathan Edlund
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Einar Heiberg
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Wallenberg Centre for Molecular Medicine, Lund University, Lund, Sweden
| | - Håkan Arheden
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Katarina Steding-Ehrenborg
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
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Alipour Symakani RS, van Genuchten WJ, Zandbergen LM, Henry S, Taverne YJHJ, Merkus D, Helbing WA, Bartelds B. The right ventricle in tetralogy of Fallot: adaptation to sequential loading. Front Pediatr 2023; 11:1098248. [PMID: 37009270 PMCID: PMC10061113 DOI: 10.3389/fped.2023.1098248] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/27/2023] [Indexed: 04/04/2023] Open
Abstract
Right ventricular dysfunction is a major determinant of outcome in patients with complex congenital heart disease, as in tetralogy of Fallot. In these patients, right ventricular dysfunction emerges after initial pressure overload and hypoxemia, which is followed by chronic volume overload due to pulmonary regurgitation after corrective surgery. Myocardial adaptation and the transition to right ventricular failure remain poorly understood. Combining insights from clinical and experimental physiology and myocardial (tissue) data has identified a disease phenotype with important distinctions from other types of heart failure. This phenotype of the right ventricle in tetralogy of Fallot can be described as a syndrome of dysfunctional characteristics affecting both contraction and filling. These characteristics are the end result of several adaptation pathways of the cardiomyocytes, myocardial vasculature and extracellular matrix. As long as the long-term outcome of surgical correction of tetralogy of Fallot remains suboptimal, other treatment strategies need to be explored. Novel insights in failure of adaptation and the role of cardiomyocyte proliferation might provide targets for treatment of the (dysfunctional) right ventricle under stress.
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Affiliation(s)
- Rahi S. Alipour Symakani
- Department of Pediatrics, Division of Pediatric Cardiology, Erasmus Medical Center, Sophia Children’s Hospital, Rotterdam, Netherlands
- Department of Cardiology, Division of Experimental Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
- Correspondence: Rahi S. Alipour Symakani
| | - Wouter J. van Genuchten
- Department of Pediatrics, Division of Pediatric Cardiology, Erasmus Medical Center, Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Lotte M. Zandbergen
- Department of Cardiology, Division of Experimental Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
- Walter Brendel Center of Experimental Medicine (WBex), University Clinic Munich, Munich, Germany
| | - Surya Henry
- Department of Pediatrics, Division of Pediatric Cardiology, Erasmus Medical Center, Sophia Children’s Hospital, Rotterdam, Netherlands
- Department of Cell Biology, Erasmus Medical Center, Rotterdam, Netherlands
| | | | - Daphne Merkus
- Department of Cardiology, Division of Experimental Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
- Walter Brendel Center of Experimental Medicine (WBex), University Clinic Munich, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany
| | - Willem A. Helbing
- Department of Pediatrics, Division of Pediatric Cardiology, Erasmus Medical Center, Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Beatrijs Bartelds
- Department of Pediatrics, Division of Pediatric Cardiology, Erasmus Medical Center, Sophia Children’s Hospital, Rotterdam, Netherlands
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Rako ZA, Kremer N, Yogeswaran A, Richter MJ, Tello K. Adaptive versus maladaptive right ventricular remodelling. ESC Heart Fail 2022; 10:762-775. [PMID: 36419369 PMCID: PMC10053363 DOI: 10.1002/ehf2.14233] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/29/2022] [Accepted: 11/04/2022] [Indexed: 11/25/2022] Open
Abstract
Right ventricular (RV) function and its adaptation to increased afterload [RV-pulmonary arterial (PA) coupling] are crucial in various types of pulmonary hypertension, determining symptomatology and outcome. In the course of disease progression and increasing afterload, the right ventricle undergoes adaptive remodelling to maintain right-sided cardiac output by increasing contractility. Exhaustion of compensatory RV remodelling (RV-PA uncoupling) finally leads to maladaptation and increase of cardiac volumes, resulting in heart failure. The gold-standard measurement of RV-PA coupling is the ratio of contractility [end-systolic elastance (Ees)] to afterload [arterial elastance (Ea)] derived from RV pressure-volume loops obtained by conductance catheterization. The optimal Ees/Ea ratio is between 1.5 and 2.0. RV-PA coupling in pulmonary hypertension has considerable reserve; the Ees/Ea threshold at which uncoupling occurs is estimated to be ~0.7. As RV conductance catheterization is invasive, complex, and not widely available, multiple non-invasive echocardiographic surrogates for Ees/Ea have been investigated. One of the first described and best validated surrogates is the ratio of tricuspid annular plane systolic excursion to estimated pulmonary arterial systolic pressure (TAPSE/PASP), which has shown prognostic relevance in left-sided heart failure and precapillary pulmonary hypertension. Other RV-PA coupling surrogates have been formed by replacing TAPSE with different echocardiographic measures of RV contractility, such as peak systolic tissue velocity of the lateral tricuspid annulus (S'), RV fractional area change, speckle tracking-based RV free wall longitudinal strain and global longitudinal strain, and three-dimensional RV ejection fraction. PASP-independent surrogates have also been studied, including the ratios S'/RV end-systolic area index, RV area change/RV end-systolic area, and stroke volume/end-systolic volume. Limitations of these non-invasive surrogates include the influence of severe tricuspid regurgitation (which can cause distortion of longitudinal measurements and underestimation of PASP) and the angle dependence of TAPSE and PASP. Detection of early RV remodelling may require isolated analysis of single components of RV shortening along the radial and anteroposterior axes as well as the longitudinal axis. Multiple non-invasive methods may need to be applied depending on the level of RV dysfunction. This review explains the mechanisms of RV (mal)adaptation to its load, describes the invasive assessment of RV-PA coupling, and provides an overview of studies of non-invasive surrogate parameters, highlighting recently published works in this field. Further large-scale prospective studies including gold-standard validation are needed, as most studies to date had a retrospective, single-centre design with a small number of participants, and validation against gold-standard Ees/Ea was rarely performed.
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Affiliation(s)
- Zvonimir A. Rako
- Department of Internal Medicine Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL) Klinikstrasse 33 35392 Giessen Germany
| | - Nils Kremer
- Department of Internal Medicine Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL) Klinikstrasse 33 35392 Giessen Germany
| | - Athiththan Yogeswaran
- Department of Internal Medicine Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL) Klinikstrasse 33 35392 Giessen Germany
| | - 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) Klinikstrasse 33 35392 Giessen Germany
| | - Khodr Tello
- Department of Internal Medicine Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL) Klinikstrasse 33 35392 Giessen Germany
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Long GM, Troutman AD, Gray DA, Fisher AJ, Lahm T, Coggan AR, Brown MB. Skeletal muscle blood flow during exercise is reduced in a rat model of pulmonary hypertension. Am J Physiol Regul Integr Comp Physiol 2022; 323:R561-R570. [PMID: 36036455 PMCID: PMC9602702 DOI: 10.1152/ajpregu.00327.2021] [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: 12/21/2021] [Revised: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 11/22/2022]
Abstract
Pulmonary arterial hypertension (PAH) is characterized by exercise intolerance. Muscle blood flow may be reduced during exercise in PAH; however, this has not been directly measured. Therefore, we investigated blood flow during exercise in a rat model of monocrotaline (MCT)-induced pulmonary hypertension (PH). Male Sprague-Dawley rats (∼200 g) were injected with 60 mg/kg MCT (MCT, n = 23) and vehicle control (saline; CON, n = 16). Maximal rate of oxygen consumption (V̇o2max) and voluntary running were measured before PH induction. Right ventricle (RV) morphology and function were assessed via echocardiography and invasive hemodynamic measures. Treadmill running at 50% V̇o2max was performed by a subgroup of rats (MCT, n = 8; CON, n = 7). Injection of fluorescent microspheres determined muscle blood flow via photo spectroscopy. MCT demonstrated a severe phenotype via RV hypertrophy (Fulton index, 0.61 vs. 0.31; P < 0.001), high RV systolic pressure (51.5 vs. 22.4 mmHg; P < 0.001), and lower V̇o2max (53.2 vs. 71.8 mL·min-1·kg-1; P < 0.0001) compared with CON. Two-way ANOVA revealed exercising skeletal muscle blood flow relative to power output was reduced in MCT compared with CON (P < 0.001), and plasma lactate was increased in MCT (10.8 vs. 4.5 mmol/L; P = 0.002). Significant relationships between skeletal blood flow and blood lactate during exercise were observed for individual muscles (r = -0.58 to -0.74; P < 0.05). No differences in capillarization were identified. Skeletal muscle blood flow is significantly reduced in experimental PH. Reduced blood flow during exercise may be, at least in part, consequent to reduced exercise intensity in PH. This adds further evidence of peripheral muscle dysfunction and exercise intolerance in PAH.
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Affiliation(s)
- Gary Marshall Long
- Department of Kinesiology, University of Indianapolis, Indianapolis, Indiana
| | - Ashley D Troutman
- Department of Kinesiology, Indiana University Purdue University Indianapolis, Indianapolis, Indiana
| | - Derrick A Gray
- Department of Kinesiology, Indiana University Purdue University Indianapolis, Indianapolis, Indiana
| | - Amanda J Fisher
- Department of Kinesiology, Indiana University Purdue University Indianapolis, Indianapolis, Indiana
| | - Tim Lahm
- Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Indiana University, Indianapolis, Indiana
- Richard L. Roudebush Veteran Affairs Medical Center, Indianapolis, Indiana
| | - Andrew R Coggan
- Department of Kinesiology, Indiana University Purdue University Indianapolis, Indianapolis, Indiana
| | - Mary Beth Brown
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
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Arena R, Ozemek C, Canada JM, Lavie CJ, Borghi-Silva A, Bond S, Popovic D, Argiento P, Guazzi M. Right Ventricular Contractile Reserve: A Key Metric to Identifying when Cardiorespiratory Fitness will Improve with Pulmonary Vasodilators. Curr Probl Cardiol 2022; 48:101423. [PMID: 36167224 DOI: 10.1016/j.cpcardiol.2022.101423] [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: 09/21/2022] [Accepted: 09/21/2022] [Indexed: 11/19/2022]
Abstract
Cardiorespiratory fitness (CRF) has been proposed as a vital sign for the past several years, supported by a wealth of evidence demonstrating its significance as a predictor of health trajectory, exercise/functional capacity, and quality of life. According to the Fick equation, oxygen consumption (VO2) is the product of cardiac output (CO) and arterial-venous oxygen difference, with the former being a primary driver of one's aerobic capacity. In terms of the dependence of aerobic capacity on a robust augmentation of CO from rest to maximal exercise, left ventricular (LV) CO has been the historic focal point. Patients with pulmonary arterial hypertension (PAH) or secondary pulmonary hypertension (PH) present with a significantly compromised CRF; as pathophysiology worsens, so too does CRF. Interventions to improve pulmonary hemodynamics continue to emerge and are now a standard of clinical care in several patient populations with increased pulmonary pressures; new pharmacologic options continue to be explored. Improvement in CRF/aerobic capacity has been and continues to be a primary or leading secondary endpoint in clinical trials examining the effectiveness of pulmonary vasodilators. A central premise for including CRF/aerobic capacity as an endpoint is that pulmonary vasodilation will lead to a significant downstream increase in LV CO and therefore peak VO2. However, the importance of right ventricular (RV) CO to the peak VO2 response continues to be overlooked. The current review provides an overview of relevant principles of exercise physiology, approaches to assessing RV contractile reserve and proposals for clinical trial design and subject phenotyping.
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Affiliation(s)
- Ross Arena
- Department of Physical Therapy, College of Applied Science, University of Illinois Chicago, Chicago, IL ; Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL.
| | - Cemal Ozemek
- Department of Physical Therapy, College of Applied Science, University of Illinois Chicago, Chicago, IL ; Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL
| | - Justin M Canada
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Carl J Lavie
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL; Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-University of Queensland School of Medicine, New Orleans, LA
| | - Audrey Borghi-Silva
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL; Cardiopulmonary Physiotherapy Laboratory, Federal University of Sao Carlos, São Carlos, SP, Brazil
| | - Samantha Bond
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL; Department of Biomedical and Health Information Sciences, College of Applied Science, University of Illinois Chicago, Chicago, IL
| | - Dejana Popovic
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL; Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia; Mayo Clinic, Rochester, Minnesota
| | - Paola Argiento
- Department of Cardiology, University "L. Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Marco Guazzi
- Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Chicago, IL; Department of Biological Sciences, San Paolo Hospital, Cardiology Division, University of Milano School of Medicine, Milano, Italy
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Omote K, Sorimachi H, Obokata M, Reddy YNV, Verbrugge FH, Omar M, DuBrock HM, Redfield MM, Borlaug BA. Pulmonary vascular disease in pulmonary hypertension due to left heart disease: pathophysiologic implications. Eur Heart J 2022; 43:3417-3431. [PMID: 35796488 PMCID: PMC9794188 DOI: 10.1093/eurheartj/ehac184] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 02/10/2022] [Accepted: 03/28/2022] [Indexed: 12/31/2022] Open
Abstract
AIMS Pulmonary hypertension (PH) and pulmonary vascular disease (PVD) are common and associated with adverse outcomes in left heart disease (LHD). This study sought to characterize the pathophysiology of PVD across the spectrum of PH in LHD. METHODS AND RESULTS Patients with PH-LHD [mean pulmonary artery (PA) pressure >20 mmHg and PA wedge pressure (PAWP) ≥15 mmHg] and controls free of PH or LHD underwent invasive haemodynamic exercise testing with simultaneous echocardiography, expired air and blood gas analysis, and lung ultrasound in a prospective study. Patients with PH-LHD were divided into isolated post-capillary PH (IpcPH) and PVD [combined post- and pre-capillary PH (CpcPH)] based upon pulmonary vascular resistance (PVR <3.0 or ≥3.0 WU). As compared with controls (n = 69) and IpcPH-LHD (n = 55), participants with CpcPH-LHD (n = 40) displayed poorer left atrial function and more severe right ventricular (RV) dysfunction at rest. With exercise, patients with CpcPH-LHD displayed similar PAWP to IpcPH-LHD, but more severe RV-PA uncoupling, greater ventricular interaction, and more severe impairments in cardiac output, O2 delivery, and peak O2 consumption. Despite higher PVR, participants with CpcPH developed more severe lung congestion compared with both IpcPH-LHD and controls, which was associated lower arterial O2 tension, reduced alveolar ventilation, decreased pulmonary O2 diffusion, and greater ventilation-perfusion mismatch. CONCLUSIONS Pulmonary vascular disease in LHD is associated with a distinct pathophysiologic signature marked by greater exercise-induced lung congestion, arterial hypoxaemia, RV-PA uncoupling, ventricular interdependence, and impairment in O2 delivery, impairing aerobic capacity. Further study is required to identify novel treatments targeting the pulmonary vasculature in PH-LHD.
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Affiliation(s)
- Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Frederik H Verbrugge
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Massar Omar
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Margaret M Redfield
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
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Tsarova K, Morgan AE, Melendres-Groves L, Ibrahim MM, Ma CL, Pan IZ, Hatton ND, Beck EM, Ferrel MN, Selzman CH, Ingram D, Alamri AK, Ratcliffe MB, Wilson BD, Ryan JJ. Imaging in Pulmonary Vascular Disease-Understanding Right Ventricle-Pulmonary Artery Coupling. Compr Physiol 2022; 12:3705-3730. [PMID: 35950653 DOI: 10.1002/cphy.c210017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The right ventricle (RV) and pulmonary arterial (PA) tree are inextricably linked, continually transferring energy back and forth in a process known as RV-PA coupling. Healthy organisms maintain this relationship in optimal balance by modulating RV contractility, pulmonary vascular resistance, and compliance to sustain RV-PA coupling through life's many physiologic challenges. Early in states of adaptation to cardiovascular disease-for example, in diastolic heart failure-RV-PA coupling is maintained via a multitude of cellular and mechanical transformations. However, with disease progression, these compensatory mechanisms fail and become maladaptive, leading to the often-fatal state of "uncoupling." Noninvasive imaging modalities, including echocardiography, magnetic resonance imaging, and computed tomography, allow us deeper insight into the state of coupling for an individual patient, providing for prognostication and potential intervention before uncoupling occurs. In this review, we discuss the physiologic foundations of RV-PA coupling, elaborate on the imaging techniques to qualify and quantify it, and correlate these fundamental principles with clinical scenarios in health and disease. © 2022 American Physiological Society. Compr Physiol 12: 1-26, 2022.
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Affiliation(s)
- Katsiaryna Tsarova
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ashley E Morgan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Lana Melendres-Groves
- Division of Pulmonary and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Majd M Ibrahim
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Christy L Ma
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Irene Z Pan
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
| | - Nathan D Hatton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Emily M Beck
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Meganne N Ferrel
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Dominique Ingram
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ayedh K Alamri
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | | | - Brent D Wilson
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Management of cardiac dysfunction in neonates with pulmonary hypertension and the role of the ductus arteriosus. Semin Fetal Neonatal Med 2022; 27:101368. [PMID: 35798649 DOI: 10.1016/j.siny.2022.101368] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pulmonary hypertension in the neonate is associated with cardiopulmonary disturbances and neurodevelopment morbidity. The patent ductus arteriosus is a persistent fetal shunt that can be pathologic vs supportive in the setting of neonatal pulmonary hypertension. Understanding the underlying pathophysiology of pulmonary hypertension and the cardiopulmonary effects of various phenotypes can guide management in this vulnerable population. In this narrative, we will summarize the physiologic principles of pulmonary hypertension, the impact of the patent ductus arteriosus on various phenotypes, and the utility of serial targeted neonatal echocardiography to individualize clinical assessment and management.
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Hayashi H, Oda S, Emoto T, Kidoh M, Nagayama Y, Nakaura T, Sakabe D, Tokuyasu S, Hirakawa K, Takashio S, Yamamoto E, Tsujita K, Hirai T. Myocardial extracellular volume quantification by cardiac CT in pulmonary hypertension: Comparison with cardiac MRI. Eur J Radiol 2022; 153:110386. [PMID: 35661458 DOI: 10.1016/j.ejrad.2022.110386] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/21/2022] [Accepted: 05/26/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Myocardial extracellular volume (ECV) measured by cardiac magnetic resonance imaging (MRI) has been suggested as a marker of disease severity in pulmonary hypertension (PH). However, consistency between ECVs quantified by computed tomography (CT) and MRI has not been sufficiently investigated in (PH). We investigated the utility of CT-ECV in PH, using MRI-ECV as a reference standard. METHOD We evaluated 20 patients with known or suspected PH who underwent dual-energy CT, cardiac MRI, and right heart catheterization. We used Pearson correlation analysis to investigate correlations between CT-ECV and MRI-ECV. We also assessed correlations between ECV and mean pulmonary artery pressure (mPAP). RESULTS CT-ECV showed a very strong correlation with MRI-ECV at the anterior (r = 0.83) and posterior right ventricular insertion points (RVIPs) (r = 0.84). CT-ECV and MRI-ECV were strongly correlated in the septum and left ventricular free wall (r = 0.79-0.73) but weakly correlated in the right ventricular free wall (r = 0.26). CT-ECV showed a strong correlation with mPAP in the anterior RVIP (r = 0.64) and a moderate correlation in the posterior RVIP and septum (r = 0.50-0.42). Compared with CT-ECV, MRI-ECV had a higher correlation with mPAP; however, the difference was not significant (anterior RVIP, r = 0.72 [MRI-ECV] vs. 0.64 [CT-ECV], p = 0.663; posterior RVIP, r = 0.67 vs. 0.50, p = 0.446). CONCLUSION Dual-energy CT can quantify myocardial ECV and yield results comparable to those obtained using cardiac MRI. CT-ECV in the anterior RVIP could be a noninvasive surrogate marker of disease severity in PH.
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Affiliation(s)
- Hidetaka Hayashi
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Seitaro Oda
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan.
| | - Takafumi Emoto
- Department of Central Radiology, Kumamoto University Hospital, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Masafumi Kidoh
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Yasunori Nagayama
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Takeshi Nakaura
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Daisuke Sakabe
- Department of Central Radiology, Kumamoto University Hospital, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Shinichi Tokuyasu
- CT Clinical Science, Philips Japan, Kohnan 2-13-37, Minato-ku, Tokyo 108-8507, Japan
| | - Kyoko Hirakawa
- Department of Cardiovascular Medicine, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
| | - Toshinori Hirai
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto 860-8556, Japan
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Vicenzi M, Caravita S, Rota I, Casella R, Deboeck G, Beretta L, Lombi A, Vachiery JL. The added value of right ventricular function normalized for afterload to improve risk stratification of patients with pulmonary arterial hypertension. PLoS One 2022; 17:e0265059. [PMID: 35587927 PMCID: PMC9119555 DOI: 10.1371/journal.pone.0265059] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 02/22/2022] [Indexed: 01/05/2023] Open
Abstract
Background Risk stratification is central to the management of pulmonary arterial hypertension (PAH). For this purpose, multiparametric tools have been developed, including the ESC/ERS risk score and its simplified versions derived from large database analysis such as the COMPERA and the French Pulmonary Hypertension Network (FPHN) registries. However, the distinction between high and intermediate-risk profiles may be difficult as the latter lacks granularity. In addition, neither COMPERA or FPHN strategies included imaging-derived markers. We thus aimed at investigating whether surrogate echocardiographic markers of right ventricular (RV) to pulmonary artery (PA) coupling could improve risk stratification in patients at intermediate-risk. Material and methods A single-center retrospective analysis including 102 patients with a diagnosis of PAH was performed. COMPERA and FPHN strategies were applied to stratify clinical risk. The univariate linear regression was used to test the influence of the echo-derived parameters qualifying the right heart (right ventricle basal diameter, right atrial area, and pressure, tricuspid regurgitation velocity, tricuspid annular plane systolic excursion -TAPSE-). Among these, the TAPSE and tricuspid regurgitation velocity ratio (TAPSE/TRV) as well as the TAPSE and systolic pulmonary artery pressure ratio (TAPSE/sPAP) were considered as surrogate of RV-PA coupling. Results TAPSE/TRV and TAPSE/sPAP resulted the more powerful markers of prognosis. Once added to COMPERA, TAPSE/TRV or TAPSE/sPAP significantly dichotomized intermediate-risk group in intermediate-to-low-risk (TAPSE/TRV≥3.74 mm∙nm/s)-1 or TAPSE/sPAP≥0.24 mm/mmHg) and in intermediate-to-high-risk subgroups (TAPSE/TRV<3.74 mm∙(m/s)-1 or TAPSE/sPAP<0.24 mm/mmHg). In the same way, TAPSE/TRV or TAPSE/sPAP was able to select patients at lower risk among those with 2, 1, and 0 low-risk criteria of both invasive and non-invasive FPHN registries. Conclusions Our results suggest that adopting functional-hemodynamic echo-derived parameters may provide a more accurate risk stratification in patients with PAH. In particular, TAPSE/TRV or TAPSE/sPAP improved risk stratification in patients at intermediate-risk, that otherwise would have remained less characterized.
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Affiliation(s)
- Marco Vicenzi
- Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
- * E-mail:
| | - Sergio Caravita
- Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy
| | - Irene Rota
- Cardiovascular Diseases Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy
| | - Rosa Casella
- Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Gael Deboeck
- Faculty of Motricity Sciences, Department of Physiotherapy, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Lorenzo Beretta
- Scleroderma Unit, Referral Center for Systemic Autoimmune Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Andrea Lombi
- Department of Health Science, Pulmonology Unit, University of Milan Bicocca, San Gerardo Hospital, Monza, Italy
| | - Jean-Luc Vachiery
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
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36
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Alenezi F, Covington TA, Mukherjee M, Mathai SC, Yu PB, Rajagopal S. Novel Approaches to Imaging the Pulmonary Vasculature and Right Heart. Circ Res 2022; 130:1445-1465. [PMID: 35482838 PMCID: PMC9060389 DOI: 10.1161/circresaha.121.319990] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
There is an increased appreciation for the importance of the right heart and pulmonary circulation in several disease states across the spectrum of pulmonary hypertension and left heart failure. However, assessment of the structure and function of the right heart and pulmonary circulation can be challenging, due to the complex geometry of the right ventricle, comorbid pulmonary airways and parenchymal disease, and the overlap of hemodynamic abnormalities with left heart failure. Several new and evolving imaging modalities interrogate the right heart and pulmonary circulation with greater diagnostic precision. Echocardiographic approaches such as speckle-tracking and 3-dimensional imaging provide detailed assessments of regional systolic and diastolic function and volumetric assessments. Magnetic resonance approaches can provide high-resolution views of cardiac structure/function, tissue characterization, and perfusion through the pulmonary vasculature. Molecular imaging with positron emission tomography allows an assessment of specific pathobiologically relevant targets in the right heart and pulmonary circulation. Machine learning analysis of high-resolution computed tomographic lung scans permits quantitative morphometry of the lung circulation without intravenous contrast. Inhaled magnetic resonance imaging probes, such as hyperpolarized 129Xe magnetic resonance imaging, report on pulmonary gas exchange and pulmonary capillary hemodynamics. These approaches provide important information on right ventricular structure and function along with perfusion through the pulmonary circulation. At this time, the majority of these developing technologies have yet to be clinically validated, with few studies demonstrating the utility of these imaging biomarkers for diagnosis or monitoring disease. These technologies hold promise for earlier diagnosis and noninvasive monitoring of right heart failure and pulmonary hypertension that will aid in preclinical studies, enhance patient selection and provide surrogate end points in clinical trials, and ultimately improve bedside care.
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Affiliation(s)
- Fawaz Alenezi
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | | | | | - Steve C. Mathai
- Johns Hopkins Division of Pulmonary and Critical Care Medicine, Baltimore, MD
| | - Paul B. Yu
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
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37
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Shima H, Nakaya T, Tsujino I, Nakamura J, Sugimoto A, Sato T, Watanabe T, Ohira H, Suzuki M, Kato M, Yokota I, Konno S. Accuracy of Swan‒Ganz catheterization‐based assessment of right ventricular function: Validation study using high‐fidelity micromanometry‐derived values as reference. Pulm Circ 2022; 12:e12078. [PMID: 35514782 PMCID: PMC9063972 DOI: 10.1002/pul2.12078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/15/2022] [Accepted: 04/06/2022] [Indexed: 11/14/2022] Open
Abstract
Right ventricular (RV) function critically affects the outcomes of patients with pulmonary hypertension (PH). Pressure wave analysis using Swan‒Ganz catheterization (SG‐cath) allows for the calculation of indices of RV function. However, the accuracy of these indices has not been validated. In the present study, we calculated indices of systolic and diastolic RV functions using SG‐cath‐derived pressure recordings in patients with suspected or confirmed PH. We analyzed and validated the accuracies of three RV indices having proven prognostic values, that is, end‐systolic elastance (Ees)/arterial elastance (Ea), β (stiffness constant), and end‐diastolic elastance (Eed), using high‐fidelity micromanometry‐derived data as reference. We analyzed 73 participants who underwent SG‐cath for the diagnosis or evaluation of PH. In this study, Ees/Ea was calculated via the single‐beat pressure method using [1.65 × (mean pulmonary arterial pressure) − 7.79] as end‐systolic pressure. SG‐cath‐derived Ees/Ea, β, and Eed were 0.89 ± 0.69 (mean ± standard deviation), 0.027 ± 0.002, and 0.16 ± 0.02 mmHg/ml, respectively. The mean differences (limits of agreement) between SG‐cath and micromanometry‐derived data were 0.13 (0.99, −0.72), 0.002 (0.020, −0.013), and 0.04 (0.20, −0.12) for Ees/Ea, β, and Eed, respectively. The intraclass correlation coefficients of the indices derived from the two catheterizations were 0.76, 0.71, and 0.57 for Ees/Ea, β, and Eed, respectively. In patients with confirmed or suspected PH, SG‐cath‐derived RV indices, especially Ees/Ea and β, exhibited a good correlation with micromanometry‐derived reference values.
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Affiliation(s)
- Hideki Shima
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Toshitaka Nakaya
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Ichizo Tsujino
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
- Division of Respiratory and Cardiovascular Innovative Research Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Junichi Nakamura
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Ayako Sugimoto
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Takahiro Sato
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
- Division of Respiratory and Cardiovascular Innovative Research Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Taku Watanabe
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Hiroshi Ohira
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
| | - Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine Hokkaido University Japan
| | - Satoshi Konno
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University Sapporo Japan
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38
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Vizza CD, Lang IM, Badagliacca R, Benza RL, Rosenkranz S, White RJ, Adir Y, Andreassen AK, Balasubramanian V, Bartolome S, Blanco I, Bourge RC, Carlsen J, Camacho REC, D’Alto M, Farber HW, Frantz RP, Ford HJ, Ghio S, Gomberg-Maitland M, Humbert M, Naeije R, Orfanos SE, Oudiz RJ, Perrone SV, Shlobin OA, Simon MA, Sitbon O, Torres F, Luc Vachiery J, Wang KY, Yacoub MH, Liu Y, Golden G, Matsubara H. Aggressive Afterload Lowering to Improve the Right Ventricle: A New Target for Medical Therapy in Pulmonary Arterial Hypertension? Am J Respir Crit Care Med 2022; 205:751-760. [PMID: 34905704 PMCID: PMC9836222 DOI: 10.1164/rccm.202109-2079pp] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Despite numerous therapeutic advances in pulmonary arterial hypertension, patients continue to suffer high morbidity and mortality, particularly considering a median age of 50 years. This article explores whether early, robust reduction of right ventricular afterload would facilitate substantial improvement in right ventricular function and thus whether afterload reduction should be a treatment goal for pulmonary arterial hypertension. The earliest clinical studies of prostanoid treatment in pulmonary arterial hypertension demonstrated an important link between lowering mean pulmonary arterial pressure (or pulmonary vascular resistance) and improved survival. Subsequent studies of oral monotherapy or sequential combination therapy demonstrated smaller reductions in mean pulmonary arterial pressure and pulmonary vascular resistance. More recently, retrospective reports of initial aggressive prostanoid treatment or initial combination oral and parenteral therapy have shown marked afterload reduction along with significant improvements in right ventricular function. Some data suggest that reaching threshold levels for pressure or resistance (components of right ventricular afterload) may be key to interrupting the self-perpetuating injury of pulmonary vascular disease in pulmonary arterial hypertension and could translate into improved long-term clinical outcomes. Based on these clues, the authors postulate that improved clinical outcomes might be achieved by targeting significant afterload reduction with initial oral combination therapy and early parenteral prostanoids.
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Affiliation(s)
- Carmine Dario Vizza
- Dipartimento di Scienze Cliniche Internistiche Anestesiologiche e Cardiovascolari, Università di Roma La Sapienza, Rome, Italy
| | - Irene M. Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche Anestesiologiche e Cardiovascolari, Università di Roma La Sapienza, Rome, Italy
| | - Raymond L. Benza
- Division of Cardiovascular Diseases, The Ohio State University, Columbus, Ohio
| | - Stephan Rosenkranz
- Department of Cardiology, Clinic III for Internal Medicine, Cologne, Germany;,Cologne Cardiovascular Research Center, Cologne, Germany
| | - R. James White
- Department of Pulmonary and Critical Care Medicine, University of Rochester, Rochester, New York
| | - Yochai Adir
- Pulmonary Division, Carmel Medical Center, Haifa, Israel;,Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Arne K. Andreassen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Vijay Balasubramanian
- Division of Pulmonary and Critical Care, Department of Medicine, University of California San Francisco Fresno, Fresno, California
| | - Sonja Bartolome
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Isabel Blanco
- Department of Pulmonary Medicine, The August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain;,Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
| | - Robert C. Bourge
- Department of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jørn Carlsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark;,Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Rafael Enrique Conde Camacho
- Critical Medicine and Intensive Care, Pulmonology, Vascular Pulmonary Center, Pulmonology Foundation of Colombia, University Clinic Colombia, Bogota, Colombia
| | - Michele D’Alto
- Department of Cardiology, University “L. Vanvitelli,” Monaldi Hospital, Naples, Italy
| | - Harrison W. Farber
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
| | - Robert P. Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - H. James Ford
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stefano Ghio
- Division of Cardiology, San Matteo Hospital, Scientific Institute for Research, Hospitalization, and Healthcare, Pavia, Italy
| | - Mardi Gomberg-Maitland
- Department of Cardiology, School of Medicine & Health Sciences, George Washington University, Washington, D.C
| | - Marc Humbert
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtr, France;,Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique–Hôpitaux de Paris, Le Kremlin-Bicêtre, France;,Unite Mixte de Recherche S999, Hôpital Marie Lannelongue–Institut National de la Santé et de la Recherche Médicale, Le Plessis-Robinson, France
| | - Robert Naeije
- Department of Cardiology, Erasme University Hospital, Brussels, Belgium
| | - Stylianos E. Orfanos
- 1st Department of Critical Care, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ronald J. Oudiz
- Division of Cardiology, Lundquist Institute for Biomedical Research at Harbor-University of California Los Angeles Medical Center, Torrance, California
| | - Sergio V. Perrone
- Departamento Cardiologia, Instituto Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia, Buenos Aires, Argentina
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Marc A. Simon
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Olivier Sitbon
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtr, France;,Service de Pneumologie et Soins Intensifs, Hôpital Bicêtre, Assistance Publique–Hôpitaux de Paris, Le Kremlin-Bicêtre, France;,Unite Mixte de Recherche S999, Hôpital Marie Lannelongue–Institut National de la Santé et de la Recherche Médicale, Le Plessis-Robinson, France
| | - Fernando Torres
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jean Luc Vachiery
- Pulmonary Vascular Diseases and Heart Failure Clinic, Department of Cardiology, Cliniques Universitaires de Bruxelles-Hôpital Erasme, Brussels, Belgium
| | - Kuo-Yang Wang
- Center for Pulmonary Hypertension and Pulmonary Vascular Disease, China University Hospital, Taichung, Taiwan
| | - Magdi H. Yacoub
- National Heart and Lung Institute, Heart Science Centre, Harefield Hospital, London, United Kingdom
| | - Yan Liu
- Department of Global Medical Affairs, United Therapeutics Corporation, Research Triangle Park, North Carolina; and
| | - Gil Golden
- Department of Global Medical Affairs, United Therapeutics Corporation, Research Triangle Park, North Carolina; and
| | - Hiromi Matsubara
- Department of Cardiology and Clinical Science, National Hospital Organization, Okayama Medical Center, Okayama, Japan
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Vos JL, Butcher SC, Fortuni F, Galloo X, Rodwell L, Vonk MC, Bax JJ, van Leuven SI, de Vries-Bouwstra JK, Snoeren M, El Messaoudi S, Marsan NA, Nijveldt R. The Prognostic Value of Right Atrial and Right Ventricular Functional Parameters in Systemic Sclerosis. Front Cardiovasc Med 2022; 9:845359. [PMID: 35369297 PMCID: PMC8969768 DOI: 10.3389/fcvm.2022.845359] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/15/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Right ventricular (RV) function is of particular importance in systemic sclerosis (SSc), since common SSc complications, such as interstitial lung disease and pulmonary hypertension may affect RV afterload. Cardiovascular magnetic resonance (CMR) is the gold standard for measuring RV function. CMR-derived RV and right atrial (RA) strain is a promising tool to detect subtle changes in RV function, and might have incremental value, however, prognostic data is lacking. Therefore, the aim of this study was to evaluate the prognostic value of RA and RV strain in SSc. Methods In this retrospective study, performed at two Dutch hospitals, consecutive SSc patients who underwent CMR were included. RV longitudinal strain (LS) and RA strain were measured. Unadjusted cox proportional hazard regression analysis and likelihood ratio tests were used to evaluate the association and incremental value of strain parameters with all-cause mortality. Results A total of 100 patients (median age 54 [46–64] years, 42% male) were included. Twenty-four patients (24%) died during a follow-up of 3.1 [1.8–5.2] years. RA reservoir [Hazard Ratio (HR) = 0.95, 95% CI 0.91–0.99, p = 0.009] and conduit strain (HR = 0.93, 95% CI 0.88–0.98, p = 0.008) were univariable predictors of all-cause mortality, while RV LS and RA booster strain were not. RA conduit strain proved to be of incremental value to sex, atrial fibrillation, NYHA class, RA maximum volume indexed, and late gadolinium enhancement (p < 0.05 for all). Conclusion RA reservoir and conduit strain are predictors of all-cause mortality in SSc patients, whereas RV LS is not. In addition, RA conduit strain showed incremental prognostic value to all evaluated clinical and imaging parameters. Therefore, RA conduit strain may be a useful prognostic marker in SSc patients.
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Affiliation(s)
- Jacqueline L. Vos
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Jacqueline L. Vos,
| | - Steele C. Butcher
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
- Department of Cardiology, Royal Perth Hospital, Perth, WA, Australia
| | - Federico Fortuni
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
- Department of Cardiology, San Giovanni Battista Hospital, Foligno, Italy
| | - Xavier Galloo
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Laura Rodwell
- Section Biostatistics, Department for Health Evidence, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Madelon C. Vonk
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jeroen J. Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Sander I. van Leuven
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Miranda Snoeren
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Saloua El Messaoudi
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nina A. Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Robin Nijveldt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
- Robin Nijveldt,
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40
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Kozitza CJ, Dharmavaram N, Tao R, Tabima DM, Chesler NC, Raza F. Pulmonary vascular distensibility with passive leg raise is comparable to exercise and predictive of clinical outcomes in pulmonary hypertension. Pulm Circ 2022; 12:e12029. [PMID: 35506089 PMCID: PMC9052989 DOI: 10.1002/pul2.12029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/24/2021] [Accepted: 12/17/2021] [Indexed: 01/26/2023] Open
Affiliation(s)
| | - Naga Dharmavaram
- Department of Medicine Cardiovascular Division Madison Wisconsin USA
| | - Ran Tao
- Department of Medicine University of Wisconsin‐Madison Madison Wisconsin USA
| | | | - Naomi C. Chesler
- Department of Biomedical Engineering, Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center University of California, Irvine Irvine California USA
| | - Farhan Raza
- Department of Medicine Cardiovascular Division Madison Wisconsin USA
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41
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Hsu S, Fang JC, Borlaug BA. Hemodynamics for the Heart Failure Clinician: A State-of-the-Art Review. J Card Fail 2022; 28:133-148. [PMID: 34389460 PMCID: PMC8748277 DOI: 10.1016/j.cardfail.2021.07.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 01/03/2023]
Abstract
Heart failure (HF) fundamentally reflects an inability of the heart to provide adequate blood flow to the body without incurring the cost of increased cardiac filling pressures. This failure occurs first during the stressed state, but progresses until hemodynamic derangements become apparent at rest. As such, the measurement and interpretation of both resting and stressed hemodynamics serve an integral role in the practice of the HF clinician. In this review, we discuss conceptual and technical best practices in the performance and interpretation of both resting and invasive exercise hemodynamic catheterization, relate important pathophysiologic concepts to clinical care, and discuss updated, evidence-based applications of hemodynamics as they pertain to the full spectrum of HF conditions.
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Affiliation(s)
- Steven Hsu
- Division of Cardiology, Dept. of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - James C Fang
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, Utah.
| | - Barry A Borlaug
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
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42
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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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43
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Naeije R, Richter MJ, Rubin LJ. The physiologic basis of pulmonary arterial hypertension. Eur Respir J 2021; 59:13993003.02334-2021. [PMID: 34737219 PMCID: PMC9203839 DOI: 10.1183/13993003.02334-2021] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/18/2021] [Indexed: 11/05/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare dyspnea-fatigue syndrome caused by a progressive increase in pulmonary vascular resistance (PVR) and eventual right ventricular (RV) failure. In spite of extensive pulmonary vascular remodeling, lung function in PAH is generally well preserved, with hyperventilation and increased physiologic dead space, but minimal changes in lung mechanics and only mild to moderate hypoxemia and hypocapnia. Hypoxemia is mainly caused by a low mixed venous PO2 from a decreased cardiac output. Hypocapnia is mainly caused by an increased chemosensitivity. Exercise limitation in PAH is cardiovascular rather than ventilatory or muscular. The extent of pulmonary vascular disease in PAH is defined by multipoint pulmonary vascular pressure-flow relationships with a correction for hematocrit. Pulsatile pulmonary vascular pressure-flow relationships in PAH allow for the assessment of RV hydraulic load. This analysis is possible either in the frequency-domain or in the time-domain. The RV in PAH adapts to increased afterload by an increased contractility to preserve its coupling to the pulmonary circulation. When this homeometric mechanism is exhausted, the RV dilates to preserve flow output by an additional heterometric mechanism. Right heart failure is then diagnosed by imaging of increased right heart dimensions and clinical systemic congestion signs and symptoms. The coupling of the RV to the pulmonary circulation is assessed by the ratio of end-systolic to arterial elastances, but these measurements are difficult. Simplified estimates of RV-PA coupling can be obtained by magnetic resonance or echocardiographic imaging of ejection fraction.
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Affiliation(s)
| | - Manuel J Richter
- Department of Internal Medicine, Justus Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Lewis J Rubin
- University of California, San Diego, La Jolla, CA, USA
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Olsen NT, Göransson C, Vejlstrup N, Carlsen J. Myocardial adaptation and exercise performance in patients with pulmonary arterial hypertension assessed with patient-specific computer simulations. Am J Physiol Heart Circ Physiol 2021; 321:H865-H880. [PMID: 34448636 DOI: 10.1152/ajpheart.00442.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Myocardial function and exercise reserve are important determinants of outcome in pulmonary arterial hypertension (PAH) but are incompletely understood. For this study, we performed subject-specific computer simulations, based on invasive measurements and cardiac magnetic resonance imaging (CMR), to investigate whole circulation properties in PAH at rest and exercise and determinants of exercise reserve. CMR and right heart catheterization were performed in nine patients with idiopathic PAH, and CMR in 10 healthy controls. CMR during exercise was performed in seven patients with PAH. A full-circulation computer model was developed, and model parameters were optimized at the individual level. Patient-specific simulations were used to analyze the effect of right ventricular (RV) inotropic reserve on exercise performance. Simulations achieved a high consistency with observed data. RV contractile force was increased in patients with PAH (127.1 ± 28.7 kPa vs. 70.5 ± 14.5 kPa, P < 0.001), whereas left ventricular contractile force was reduced (107.5 ± 17.5 kPa vs. 133.9 ± 10.3 kPa, P = 0.002). During exercise, RV contractile force increased by 1.56 ± 0.17, P = 0.001. In silico experiments confirmed RV inotropic reserve as the important limiting factor for cardiac output. Subject-specific computer simulation of myocardial mechanics in PAH is feasible and can be used to evaluate myocardial performance. With this method, we demonstrate marked functional myocardial adaptation to PAH in the resting state, primarily composed of increased contractile force development by RV myofibers, and we show the negative impact of reduced RV inotropic reserve on cardiac output during exercise.NEW & NOTEWORTHY Computer simulations of the myocardial mechanics and hemodynamics of rest and exercise were performed in nine patients with pulmonary arterial hypertension and 10 control subjects, with the use of data from invasive catheterization and from cardiac magnetic resonance. This approach allowed a detailed analysis of myocardial adaptation to pulmonary arterial hypertension and showed how reduction in right ventricular inotropic reserve is the important limiting factor for an increase in cardiac output during exercise.
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Affiliation(s)
- Niels Thue Olsen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christoffer Göransson
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Niels Vejlstrup
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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45
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Brown JT, Kotecha T, Steeden JA, Fontana M, Denton CP, Coghlan JG, Knight DS, Muthurangu V. Reduced exercise capacity in patients with systemic sclerosis is associated with lower peak tissue oxygen extraction: a cardiovascular magnetic resonance-augmented cardiopulmonary exercise study. J Cardiovasc Magn Reson 2021; 23:118. [PMID: 34706740 PMCID: PMC8554852 DOI: 10.1186/s12968-021-00817-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/24/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Exercise intolerance in systemic sclerosis (SSc) is typically attributed to cardiopulmonary limitations. However, problems with skeletal muscle oxygen extraction have not been fully investigated. This study used cardiovascular magnetic resonance (CMR)-augmented cardiopulmonary exercise testing (CMR-CPET) to simultaneously measure oxygen consumption and cardiac output. This allowed calculation of arteriovenous oxygen content gradient, a recognized marker of oxygen extraction. We performed CMR-CPET in 4 groups: systemic sclerosis (SSc); systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH); non-connective tissue disease pulmonary hypertension (NC-PAH); and healthy controls. METHODS We performed CMR-CPET in 60 subjects (15 in each group) using a supine ergometer following a ramped exercise protocol until exhaustion. Values for oxygen consumption, cardiac output and oxygen content gradient, as well as ventricular volumes, were obtained at rest and peak-exercise for all subjects. In addition, T1 and T2 maps were acquired at rest, and the most recent clinical measures (hemoglobin, lung function, 6-min walk, cardiac and catheterization) were collected. RESULTS All patient groups had reduced peak oxygen consumption compared to healthy controls (p < 0.022). The SSc and SSc-PAH groups had reduced peak oxygen content gradient compared to healthy controls (p < 0.03). Conversely, the SSc-PAH and NC-PH patients had reduced peak cardiac output compared to healthy controls and SSc patients (p < 0.006). Higher hemoglobin was associated with higher peak oxygen content gradient (p = 0.025) and higher myocardial T1 was associated with lower peak stroke volume (p = 0.011). CONCLUSIONS Reduced peak oxygen consumption in SSc patients is predominantly driven by reduced oxygen content gradient and in SSc-PAH patients this was amplified by reduced peak cardiac output. Trial registration The study is registered with ClinicalTrials.gov Protocol Registration and Results System (ClinicalTrials.gov ID: 100358).
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Affiliation(s)
- James T Brown
- Institute of Cardiovascular Science, University College London, London, UK
- Royal Free Hospital, London, UK
| | - Tushar Kotecha
- Institute of Cardiovascular Science, University College London, London, UK
- Royal Free Hospital, London, UK
| | - Jennifer A Steeden
- Institute of Cardiovascular Science, University College London, London, UK
| | - Marianna Fontana
- Royal Free Hospital, London, UK
- Division of Medicine, University College London, London, UK
| | - Christopher P Denton
- Royal Free Hospital, London, UK
- Division of Medicine, University College London, London, UK
| | | | - Daniel S Knight
- Institute of Cardiovascular Science, University College London, London, UK
- Royal Free Hospital, London, UK
| | - Vivek Muthurangu
- Institute of Cardiovascular Science, University College London, London, UK.
- Centre for Cardiovascular Imaging, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK.
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46
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Vanderpool RR, Hunter KS, Insel M, Garcia JGN, Bedrick EJ, Tedford RJ, Rischard FP. The Right Ventricular-Pulmonary Arterial Coupling and Diastolic Function Response to Therapy in Pulmonary Arterial Hypertension. Chest 2021; 161:1048-1059. [PMID: 34637777 DOI: 10.1016/j.chest.2021.09.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/14/2021] [Accepted: 09/25/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Multiparametric risk assessment is used in pulmonary arterial hypertension (PAH) to target therapy. However, this strategy is imperfect as most patients remain in intermediate or high risk after initial treatment with low risk being the goal. Metrics of right ventricular (RV) adaptation are promising tools that may help refine our therapeutic strategy. RESEARCH QUESTION Does RV adaptation predict therapeutic response over time? STUDY DESIGN AND METHODS We evaluated 52 incident treatment naïve patients with advanced PAH by catheterization and cardiac imaging longitudinally at baseline, follow-up 1 (∼3 mo.) and follow-up 2 (∼18 mo.). All patients were placed on goal-directed therapy with parenteral treprostinil and/or combination therapy with treatment escalation if functional class I-II was not achieved. Therapeutic response was evaluated at follow-up 1 as non-responders (died) or responders and again at follow-up 2 as super-responders (low risk) or partial-responders (high/intermediate risk). Multiparametric risk was based on a simplified ERS/ESC guideline score. RV adaptation was evaluated with the single-beat coupling ratio (Ees/Ea) and diastolic function with diastolic elastance (Eed). Data are expressed as mean±SD or odds ratio [95%CI]. RESULTS Nine patients (17%) were non-responders. PAH-directed therapy improved ERS low risk from 1 (2%) at baseline to 23 (55%) at follow-up 2. Ees/Ea at presentation was non-significantly higher in responders (0.9±0.4) versus non-responders (0.6±0.4, p=0.09) but was unable to predict super-responder status at follow-up 2 (odds ratio 1.40 [0.28-7.0], p=0.84). Baseline RVEF and change in Eed successfully predicted super-responder status at follow-up 2 (odds ratio 1.15 [1.0-1.27], p=0.009 and 0.29 [0.86-0.96], p=0.04, respectively). INTERPRETATION In patients with advanced PAH, RV-PA coupling could not discriminate irreversible RV failure (non-responders) at presentation but showed a late trend to improvement by follow-up 2. Early change in Eed and baseline RVEF were the best predictors of therapeutic response.
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Affiliation(s)
| | - Kendall S Hunter
- Department of Bioengineering and Cardiology, UC Denver Medical Campus, Denver, CO
| | - Michael Insel
- Division of Pulmonary, Critical Care, Sleep, and Allergy Medicine, University of Arizona, Tucson, AZ
| | - Joe G N Garcia
- Department of Medicine, University of Arizona, Tucson, AZ; Division of Pulmonary, Critical Care, Sleep, and Allergy Medicine, University of Arizona, Tucson, AZ
| | - Edward J Bedrick
- BIO5 Institute, Center of Biostatistics and Informatics, University of Arizona, Tucson, AZ
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Franz P Rischard
- Department of Medicine, University of Arizona, Tucson, AZ; Division of Pulmonary, Critical Care, Sleep, and Allergy Medicine, University of Arizona, Tucson, AZ.
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47
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Sato T, Ambale-Venkatesh B, Zimmerman SL, Tedford RJ, Hsu S, Chamera E, Fujii T, Mullin CJ, Mercurio V, Khair R, Corona-Villalobos CP, Simpson CE, Damico RL, Kolb TM, Mathai SC, Lima JA, Kass DA, Tsujino I, Hassoun PM. Right ventricular function as assessed by cardiac magnetic resonance imaging-derived strain parameters compared to high-fidelity micromanometer catheter measurements. Pulm Circ 2021; 11:20458940211032529. [PMID: 34603686 PMCID: PMC8481729 DOI: 10.1177/20458940211032529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022] Open
Abstract
Right ventricular function has prognostic significance in patients with pulmonary hypertension. We evaluated whether cardiac magnetic resonance-derived strain and strain rate parameters could reliably reflect right ventricular systolic and diastolic function in precapillary pulmonary hypertension. End-systolic elastance and the time constant of right ventricular relaxation tau, both derived from invasive high-fidelity micromanometer catheter measurements, were used as gold standards for assessing systolic and diastolic right ventricular function, respectively. Nineteen consecutive precapillary pulmonary hypertension patients underwent cardiac magnetic resonance and right heart catheterization prospectively. Cardiac magnetic resonance data were compared with those of 19 control subjects. In pulmonary hypertension patients, associations between strain- and strain rate-related parameters and invasive hemodynamic parameters were evaluated. Longitudinal peak systolic strain, strain rate, and early diastolic strain rate were lower in PAH patients than in controls; peak atrial-diastolic strain rate was higher in pulmonary hypertension patients. Similarly, circumferential peak systolic strain rate was lower and peak atrial-diastolic strain rate was higher in pulmonary hypertension. In pulmonary hypertension, no correlations existed between cardiac magnetic resonance-derived and hemodynamically derived measures of systolic right ventricular function. Regarding diastolic parameters, tau was significantly correlated with peak longitudinal atrial-diastolic strain rate (r = -0.61), deceleration time (r = 0.75), longitudinal systolic to diastolic time ratio (r = 0.59), early diastolic strain rate (r = -0.5), circumferential peak atrial-diastolic strain rate (r = -0.52), and deceleration time (r = 0.62). Strain analysis of the right ventricular diastolic phase is a reliable non-invasive method for detecting right ventricular diastolic dysfunction in PAH.
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Affiliation(s)
- Takahiro Sato
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bharath Ambale-Venkatesh
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stefan L. Zimmerman
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ela Chamera
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tomoki Fujii
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Valentina Mercurio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rubina Khair
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Celia P. Corona-Villalobos
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Catherine E. Simpson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rachel L. Damico
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Todd M. Kolb
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joao A.C. Lima
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David A. Kass
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ichizo Tsujino
- First Department of Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Paul M. Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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48
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Kwan ED, Vélez-Rendón D, Zhang X, Mu H, Patel M, Pursell E, Stowe J, Valdez-Jasso D. Distinct time courses and mechanics of right ventricular hypertrophy and diastolic stiffening in a male rat model of pulmonary arterial hypertension. Am J Physiol Heart Circ Physiol 2021; 321:H702-H715. [PMID: 34448637 PMCID: PMC8794227 DOI: 10.1152/ajpheart.00046.2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 07/30/2021] [Accepted: 08/17/2021] [Indexed: 11/22/2022]
Abstract
Although pulmonary arterial hypertension (PAH) leads to right ventricle (RV) hypertrophy and structural remodeling, the relative contributions of changes in myocardial geometric and mechanical properties to systolic and diastolic chamber dysfunction and their time courses remain unknown. Using measurements of RV hemodynamic and morphological changes over 10 wk in a male rat model of PAH and a mathematical model of RV mechanics, we discriminated the contributions of RV geometric remodeling and alterations of myocardial material properties to changes in systolic and diastolic chamber function. Significant and rapid RV hypertrophic wall thickening was sufficient to stabilize ejection fraction in response to increased pulmonary arterial pressure by week 4 without significant changes in systolic myofilament activation. After week 4, RV end-diastolic pressure increased significantly with no corresponding changes in end-diastolic volume. Significant RV diastolic chamber stiffening by week 5 was not explained by RV hypertrophy. Instead, model analysis showed that the increases in RV end-diastolic chamber stiffness were entirely attributable to increased resting myocardial material stiffness that was not associated with significant myocardial fibrosis or changes in myocardial collagen content or type. These findings suggest that whereas systolic volume in this model of RV pressure overload is stabilized by early RV hypertrophy, diastolic dilation is prevented by subsequent resting myocardial stiffening.NEW & NOTEWORTHY Using a novel combination of hemodynamic and morphological measurements over 10 wk in a male rat model of PAH and a mathematical model of RV mechanics, we found that compensated systolic function was almost entirely explained by RV hypertrophy, but subsequently altered RV end-diastolic mechanics were primarily explained by passive myocardial stiffening that was not associated with significant collagen extracellular matrix accumulation.
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MESH Headings
- Animals
- Biomechanical Phenomena
- Diastole
- Disease Models, Animal
- Fibrosis
- Heart Ventricles/pathology
- Heart Ventricles/physiopathology
- Hypertrophy, Right Ventricular/etiology
- Hypertrophy, Right Ventricular/pathology
- Hypertrophy, Right Ventricular/physiopathology
- Male
- Models, Cardiovascular
- Myocardium/pathology
- Pulmonary Arterial Hypertension/complications
- Pulmonary Arterial Hypertension/physiopathology
- Rats, Sprague-Dawley
- Systole
- Time Factors
- Ventricular Dysfunction, Right/etiology
- Ventricular Dysfunction, Right/pathology
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Function, Right
- Ventricular Remodeling
- Rats
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Affiliation(s)
- Ethan D Kwan
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | - Daniela Vélez-Rendón
- Department of Bioengineering, University of Illinois at Chicago, Chicago, Illinois
| | - Xiaoyan Zhang
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | - Hao Mu
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | - Megh Patel
- College of Medicine, Texas A&M University, College Station, Texas
| | - Erica Pursell
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | - Jennifer Stowe
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | - Daniela Valdez-Jasso
- Department of Bioengineering, University of California San Diego, La Jolla, California
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49
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Bermudez CA, Crespo MM, Shlobin OA, Cantu E, Mazurek JA, Levine D, Gutsche J, Kanwar M, Dellgren G, Bush EL, Heresi GA, Cypel M, Hadler R, Kolatis N, Franco V, Benvenuto L, Mooney J, Pipeling M, King C, Mannem H, Raman S, Knoop C, Douglas A, Mercier O. ISHLT consensus document on lung transplantation in patients with connective tissue disease: Part II: Cardiac, surgical, perioperative, operative, and post-operative challenges and management statements. J Heart Lung Transplant 2021; 40:1267-1278. [PMID: 34404570 DOI: 10.1016/j.healun.2021.07.016] [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: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 01/09/2023] Open
Abstract
Patients with connective tissue disease (CTD) present unique surgical, perioperative, operative, and postoperative challenges related to the often underlying severe pulmonary hypertension and right ventricular dysfunction. The International Society for Heart and Lung Transplantation-supported consensus document on lung transplantation in patients with CTD standardization addresses the surgical challenges and relevant cardiac involvement in the perioperative, operative, and postoperative management in patients with CTD.
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Affiliation(s)
- Christian A Bermudez
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Oksana A Shlobin
- Department of Pulmonary and Critical Care Medicine, Inova Fairfax Hospital, Falls Church, Virginia
| | - Edward Cantu
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy A Mazurek
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Deborah Levine
- Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center San Antonio, Texas
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Göran Dellgren
- Department of Cardiothoracic Surgery and Transplant Institute, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Errol L Bush
- Division of Thoracic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Marcello Cypel
- Division of Thoracic Surgery, Toronto General Hospital UHN, Toronto, Ontario, Canada
| | - Rachel Hadler
- Division of Critical Care, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Nicholas Kolatis
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco Medical Center, San Francisco, California
| | - Veronica Franco
- Department of Cardiology, The Ohio State university Wexner Medical Center, Columbus, Ohio
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical center, New York, New York
| | - Joshua Mooney
- Division of Pulmonary and Critical Care Medicine, Stanford Health Care, Palo Alto, California
| | - Matthew Pipeling
- Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
| | - Christopher King
- Department of Pulmonary and Critical Care Medicine, Inova Fairfax Hospital, Falls Church, Virginia
| | - Hannah Mannem
- Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, Virginia
| | - Sanjeev Raman
- Division of Pulmonary Medicine, University of Utah, Salt Lake City, Utah
| | | | - Aaron Douglas
- Division of Anesthesiology and Critical Care, Cleveland Clinic, Cleveland, Ohio
| | - Olaf Mercier
- Department of Thoracic Surgery, Université Paris-Saclay, Marie Lannelongue Hospital, Le Plessis Robinson, France
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50
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Zaky A, Zafar I, Masjoan-Juncos JX, Husain M, Mariappan N, Morgan CJ, Hamid T, Frölich MA, Ahmad S, Ahmad A. Echocardiographic, Biochemical, and Electrocardiographic Correlates Associated With Progressive Pulmonary Arterial Hypertension. Front Cardiovasc Med 2021; 8:705666. [PMID: 34355033 PMCID: PMC8329095 DOI: 10.3389/fcvm.2021.705666] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/09/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Pulmonary arterial hypertension (PAH) is a progressive proliferative vasculopathy associated with mechanical and electrical changes, culminating in increased vascular resistance, right ventricular (RV) failure, and death. With a main focus on invasive tools, there has been an underutilization of echocardiography, electrocardiography, and biomarkers to non-invasively assess the changes in myocardial and pulmonary vascular structure and function during the course of PAH. Methods: A SU5416-hypoxia rat model was used for inducing PAH. Biventricular functions were measured using transthoracic two-dimensional (2D) echocardiography/Doppler (echo/Doppler) at disease onset (0 week), during progression (3 weeks), and establishment (5 weeks). Similarly, electrocardiography was performed at 0, 3, and 5 weeks. Invasive hemodynamic measurements and markers of cardiac injury in plasma were assessed at 0, 3, and 5 weeks. Results: Increased RV systolic pressure (RVSP) and rate of isovolumic pressure rise and decline were observed at 0, 3, and 5 weeks in PAH animals. EKG showed a steady increase in QT-interval with progression of PAH, whereas P-wave height and RS width were increased only during the initial stages of PAH progression. Echocardiographic markers of PAH progression and severity were also identified. Three echocardiographic patterns were observed: a steady pattern (0-5 weeks) in which echo parameter changed progressively with severity [inferior vena cava (IVC) expiratory diameter and pulmonary artery acceleration time (PAAT)], an early pattern (0-3 weeks) where there is an early change in parameters [RV fractional area change (RV-FAC), transmitral flow, left ventricle (LV) output, estimated mean PA pressure, RV performance index, and LV systolic eccentricity index], and a late pattern (3-5 weeks) in which there is only a late rise at advanced stages of PAH (LV diastolic eccentricity index). RVSP correlated with PAAT, PAAT/PA ejection times, IVC diameters, RV-FAC, tricuspid systolic excursion, LV systolic eccentricity and output, and transmitral flow. Plasma myosin light chain (Myl-3) and cardiac troponin I (cTnI) increased progressively across the three time points. Cardiac troponin T (cTnT) and fatty acid-binding protein-3 (FABP-3) were significantly elevated only at the 5-week time point. Conclusion: Distinct electrocardiographic and echocardiographic patterns along with plasma biomarkers were identified as useful non-invasive tools for monitoring PAH progression.
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Affiliation(s)
- Ahmed Zaky
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Iram Zafar
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Juan Xavier Masjoan-Juncos
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Maroof Husain
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Nithya Mariappan
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Charity J. Morgan
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Tariq Hamid
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Michael A. Frölich
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Shama Ahmad
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Aftab Ahmad
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
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