1
|
Huston JH, Brittain EL, Robbins IM. Pulmonary Hypertension and Right Ventricular Failure: Lung Transplant Versus Heart-Lung Transplant. Cardiol Clin 2020; 38:269-281. [PMID: 32284103 DOI: 10.1016/j.ccl.2020.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Pulmonary arterial hypertension is a highly morbid disease with limited treatment options that improve survival and currently the only curative treatment is transplantation. There is a small body of literature comparing the efficacy of lung and heart-lung transplantation in this population. The bulk of evidence suggests that most patients with severe right ventricular failure undergoing transplant will have recovery of right ventricular function after lung transplantation. Existing data suggest that, in the absence of complex congenital heart disease or significant left ventricular dysfunction, double-lung transplant is the surgical procedure of choice.
Collapse
Affiliation(s)
- Jessica H Huston
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Avenue South, Suite 5037, Nashville, TN 37232, USA.
| | - Evan L Brittain
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 300A, Nashville, TN 37203, USA
| | - Ivan M Robbins
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, T1218 MCN, Nashville, TN, USA
| |
Collapse
|
2
|
Wang Z, Patel JR, Schreier DA, Hacker TA, Moss RL, Chesler NC. Organ-level right ventricular dysfunction with preserved Frank-Starling mechanism in a mouse model of pulmonary arterial hypertension. J Appl Physiol (1985) 2018; 124:1244-1253. [PMID: 29369739 PMCID: PMC6008075 DOI: 10.1152/japplphysiol.00725.2017] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 01/08/2018] [Accepted: 01/22/2018] [Indexed: 01/08/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rapidly fatal disease in which mortality is due to right ventricular (RV) failure. It is unclear whether RV dysfunction initiates at the organ level or the subcellular level or both. We hypothesized that chronic pressure overload-induced RV dysfunction begins at the organ level with preserved Frank-Starling mechanism in myocytes. To test this hypothesis, we induced PAH with Sugen + hypoxia (HySu) in mice and measured RV whole organ and subcellular functional changes by in vivo pressure-volume measurements and in vitro trabeculae length-tension measurements, respectively, at multiple time points for up to 56 days. We observed progressive changes in RV function at the organ level: in contrast to early PAH (14-day HySu), in late PAH (56-day HySu) ejection fraction and ventricular-vascular coupling were decreased. At the subcellular level, direct measurements of myofilament contraction showed that RV contractile force was similarly increased at any stage of PAH development. Moreover, cross-bridge kinetics were not changed and length dependence of force development (Frank-Starling relation) were not different from baseline in any PAH group. Histological examinations confirmed increased cardiomyocyte cross-sectional area and decreased von Willebrand factor expression in RVs with PAH. In summary, RV dysfunction developed at the organ level with preserved Frank-Starling mechanism in myofilaments, and these results provide novel insight into the development of RV dysfunction, which is critical to understanding the mechanisms of RV failure. NEW & NOTEWORTHY A multiscale investigation of pulmonary artery pressure overload in mice showed time-dependent organ-level right ventricular (RV) dysfunction with preserved Frank-Starling relations in myofilaments. Our findings provide novel insight into the development of RV dysfunction, which is critical to understanding mechanisms of RV failure.
Collapse
Affiliation(s)
- Zhijie Wang
- Department of Biomedical Engineering, University of Wisconsin-Madison , Madison, Wisconsin
- Department of Mechanical Engineering, Colorado State University , Fort Collins, Colorado
| | - Jitandrakumar R Patel
- Department of Cell and Regenerative Biology, University of Wisconsin-Madison , Madison, Wisconsin
| | - David A Schreier
- Department of Biomedical Engineering, University of Wisconsin-Madison , Madison, Wisconsin
| | - Timothy A Hacker
- Department of Medicine, University of Wisconsin-Madison , Madison, Wisconsin
| | - Richard L Moss
- Department of Cell and Regenerative Biology, University of Wisconsin-Madison , Madison, Wisconsin
| | - Naomi C Chesler
- Department of Biomedical Engineering, University of Wisconsin-Madison , Madison, Wisconsin
- Department of Medicine, University of Wisconsin-Madison , Madison, Wisconsin
| |
Collapse
|
3
|
Gorter TM, Verschuuren EAM, van Veldhuisen DJ, Hoendermis ES, Erasmus ME, Bogaard HJ, Vonk Noordegraaf A, Berger RMF, van Melle JP, Willems TP. Right ventricular recovery after bilateral lung transplantation for pulmonary arterial hypertension†. Interact Cardiovasc Thorac Surg 2017; 24:890-897. [PMID: 28329267 DOI: 10.1093/icvts/ivx025] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/03/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Pulmonary arterial hypertension (PAH) is a progressive and often fatal disease characterized by increased pulmonary vascular resistance (PVR) and right ventricular (RV) failure. End-stage PAH is often an indication for a lung transplant (LTX). Our goal was to study ventricular recovery using cardiac magnetic resonance imaging late after LTX. METHODS We studied 10 patients with PAH who underwent isolated bilateral LTX. RV and left ventricular (LV) volumes, function and mass were measured. In addition, the RV stroke volume/end-systolic ratio (SV/ESV), the LV eccentricity index, the RV/LV volume ratio, the area of the tricuspid valve annulus and the severity of tricuspid regurgitation (TR) were calculated. RESULTS The median age was 44 [30-54] years and the mean PVR was 1020 ± 435 dynes·s·cm - 5 . Six patients had ≥ moderate TR. After LTX, the RV ejection fraction increased from 32 to 64% ( P < 0.001) and both RV volume (from 118 to 51 ml/m 2 , P < 0.001) and RV mass (from 69 to 33 g/m 2 , P < 0.001) decreased. The mean SV/ESV ratio increased from 0.5 to 1.9 ( P < 0.001) and the LV mass increased from 55 to 61 g/m 2 ( P = 0.005). There was a decrease in both the LV eccentricity index (from 2.8 to 1.1, P < 0.001) and the RV/LV volume ratio (from 2.3 to 0.8, P < 0.001). The area of the tricuspid valve annulus also decreased (from 9.8 to 4.6 cm 2 /m 2 , P < 0.001); no patient had ≥ mild TR post-LTX. CONCLUSIONS Cardiac magnetic resonance imaging confirms ventricular recovery after isolated bilateral LTX for end-stage PAH.
Collapse
Affiliation(s)
- Thomas M Gorter
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Erik A M Verschuuren
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Elke S Hoendermis
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Michiel E Erasmus
- Department of Thoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Harm J Bogaard
- Department of Pulmonary Medicine, VU University Medical Center, Amsterdam, Netherlands
| | | | - Rolf M F Berger
- Department of Paediatric Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Joost P van Melle
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Tineke P Willems
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| |
Collapse
|
4
|
Abstract
Anesthesia for lung transplantation is both a demand ing and rewarding experience. Success requires team- work, experience, knowledge of cardiorespiratory patho physiology and its anesthetic implications, appropriate use of noninvasive and invasive monitoring, and the ability to respond quickly and effectively to life- threatening perioperative events. Specific issues in clude management of a patient with end-stage lung and heart disease, lung isolation and one-lung ventilation, perioperative respiratory failure, pulmonary hyperten sion, and acute right ventricular failure. Recent ad vances include greater understanding of dynamic hyper inflation ("gas-trapping") during mechanical ventilation, perioperative use of inhaled nitric oxide and treatment of acute right ventricular failure. Successful anesthetic management leads to greater hemodynamic stability, improvement in gas exchange and a reduction in need for cardiopulmonary bypass, all of which should lead to improved patient outcome.
Collapse
Affiliation(s)
- Paul S. Myles
- Department of Anaesthesia and Pain Management, Alfred Hospital, Melbourne, Australia
| |
Collapse
|
5
|
Hill C, Maxwell B, Boulate D, Haddad F, Ha R, Afshar K, Weill D, Dhillon GS. Heart-lung vs. double-lung transplantation for idiopathic pulmonary arterial hypertension. Clin Transplant 2015; 29:1067-75. [DOI: 10.1111/ctr.12628] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Charles Hill
- Department of Anesthesiology; Perioperative and Pain Medicine; Stanford University School of Medicine; Stanford CA USA
| | - Bryan Maxwell
- Department of Anesthesiology and Critical Care Medicine; Johns Hopkins University School of Medicine; Baltimore MD USA
| | - David Boulate
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation; Centre Chirurgical Marie Lannelongue; Le Plessis-Robinson; Paris-Sud University; Paris France
| | - Francois Haddad
- Department of Medicine; Stanford University School of Medicine; Stanford CA USA
| | - Richard Ha
- Department of Cardiothoracic Surgery; Stanford University School of Medicine; Stanford CA USA
| | | | - David Weill
- Department of Medicine; Stanford University School of Medicine; Stanford CA USA
| | - Gundeep S. Dhillon
- Department of Medicine; Stanford University School of Medicine; Stanford CA USA
| |
Collapse
|
6
|
Voelkel NF, Natarajan R, Drake JI, Bogaard HJ. Right ventricle in pulmonary hypertension. Compr Physiol 2013; 1:525-40. [PMID: 23737184 DOI: 10.1002/cphy.c090008] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
During heart development chamber specification is controlled and directed by a number of genes and a fetal heart gene expression pattern is revisited during heart failure. In the setting of chronic pulmonary hypertension the right ventricle undergoes hypertrophy, which is likely initially adaptive, but often followed by decompensation, dilatation and failure. Here we discuss differences between the right ventricle and the left ventricle of the heart and begin to describe the cellular and molecular changes which characterize right heart failure. A prevention and treatment of right ventricle failure becomes a treatment goal for patients with severe pulmonary hypertension it follows that we need to understand the pathobiology of right heart hypertrophy and the transition to right heart failure.
Collapse
Affiliation(s)
- Norbert F Voelkel
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, The Victoria Johnson Center for Pulmonary Obstructive Disease Research, Virginia Commonwealth University, Richmond, Virginia, USA.
| | | | | | | |
Collapse
|
7
|
Kim SY, Lee JH, Huh JW, Kim HJ, Park MK, Ro JY, Oh YM, Lee SD, Lee YS. Bortezomib alleviates experimental pulmonary arterial hypertension. Am J Respir Cell Mol Biol 2012; 47:698-708. [PMID: 22842494 DOI: 10.1165/rcmb.2011-0331oc] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Vascular remodeling and endothelial dysfunction are important pathogenic features of pulmonary arterial hypertension (PAH). There is a growing body of evidence that proteasome inhibitors may be beneficial in vascular diseases by inhibiting proliferation of vascular smooth muscle cells (VSMCs) and ameliorating endothelial dysfunction. Here, we evaluated whether bortezomib (BTZ) could alleviate hypoxia- and monocrotaline (MCT)-induced PAH. BTZ (at doses from 1 to 100 μg/kg, or a dose of 100 μg/kg) was administered to mice every other day for the last 2 weeks of a 5-week hypoxia (10% O(2)) period, or to rats once daily from Day 22 to Day 34 after MCT challenge, respectively. BTZ treatment substantially suppressed elevation of right ventricular (RV) systolic pressure, RV hypertrophy, and pulmonary vascular remodeling in hypoxia-exposed mice. Similarly, BTZ treatment inhibited RV hypertrophy and vascular remodeling in MCT-injected rats. Strikingly, BTZ rescued 70% of MCT-injected rats up to Day 60, along with a considerable reduction in RV systolic pressure and suppression of vascular remodeling, whereas, among MCT-injected rats not administered BTZ, there were no survivors by Day 41. BTZ significantly suppressed proliferation of pulmonary VSMCs in vivo and in vitro. Furthermore, BTZ increased not only endothelial nitric oxide (NO) synthase (eNOS), phosphorylated eNOS, and NO production in vitro, but also eNOS and p-eNOS in hypoxia-exposed mice and MCT-injected rats, respectively. In contrast to the beneficial effects, BTZ increased active caspase-3 in cardiac ventricles of MCT-injected rats. Taken together, with caution for cardiotoxicity, BTZ could be a potential therapeutic strategy in PAH, possibly acting by inhibition of VSMC proliferation and amelioration of endothelial dysfunction.
Collapse
Affiliation(s)
- Sun-Yong Kim
- Division of Pharmacology, Sungkyunkwan University School of Medicine, Samsung Biomedical Research Institute, 300 Chunchun-dong, Jangan-gu, Suwon 440-746, Republic of Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Drake JI, Bogaard HJ, Mizuno S, Clifton B, Xie B, Gao Y, Dumur CI, Fawcett P, Voelkel NF, Natarajan R. Molecular signature of a right heart failure program in chronic severe pulmonary hypertension. Am J Respir Cell Mol Biol 2011; 45:1239-47. [PMID: 21719795 DOI: 10.1165/rcmb.2010-0412oc] [Citation(s) in RCA: 163] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Right heart failure is the cause of death of most patients with severe pulmonary arterial hypertensive (PAH) disorders, yet little is known about the cellular and molecular causes of right ventricular failure (RVF). We first showed a differential gene expression pattern between normal rat right and left ventricles, and postulated the existence of a molecular right heart failure program that distinguishes RVF from adaptive right ventricular hypertrophy (RVH), and that may differ in some respects from a left heart failure program. By means of microarrays and transcriptional sequencing strategies, we used two models of adaptive RVH to characterize a gene expression pattern reflective of growth and the maintenance of myocardial structure. Moreover, two models of RVF were associated with fibrosis, capillary rarefaction, the decreased expression of genes encoding the angiogenesis factors vascular endothelial growth factor, insulin-like growth factor 1, apelin, and angiopoeitin-1, and the increased expression of genes encoding a set of glycolytic enzymes. The treatment of established RVF with a β-adrenergic receptor blocker reversed RVF, and partly reversed the molecular RVF program. We conclude that normal right and left ventricles demonstrate clearly discernable differences in the expression of mRNA and microRNA, and that RVH and RVF are characterized by distinct patterns of gene expression that relate to cell growth, angiogenesis, and energy metabolism.
Collapse
Affiliation(s)
- Jennifer I Drake
- Department of Microbiology, Virginia Commonwealth University, Richmond, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Steiner S, Strauer BE. [Pathophysiology of the right ventricle in lung diseases]. Internist (Berl) 2009; 50:1054, 1056-8, 1060, passim. [PMID: 19585094 DOI: 10.1007/s00108-009-2334-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The thin-walled right heart is characterized by a low mass-volume-relation. Right ventricular function is influenced basically by loading conditions (afterload and preload), myocardial perfusion, contractility and heart rate. Afterload is determined by intrathoracal and pulmonary vascular pressure/resistance. Morphologic adaptions of the right ventricle affect right ventricular function in cor pulmonale. So the normal, not hypertrophied right ventricle is extremely sensitive to increasing pulmonary artery pressure. Otherwise, minor reductions in afterload lead to a substantial decrease of right ventricular wall stress, myocardial oxygen demand and likely the risk of arrhythmia. Therefore clinical consequences and complications of pulmonary hypertension are substantially dependent on right ventricular dynamics.
Collapse
Affiliation(s)
- S Steiner
- Klinik für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Deutschland.
| | | |
Collapse
|
10
|
Abstract
Lung transplantation is a surgical option for patients who fail optimization of medical treatment for the severe symptoms that result from COPD. This review will discuss patient selection, transplant listing, and the surgical technique for transplantation in COPD. Furthermore, it will describe transplant outcomes and its effects on recipient survival, pulmonary function, exercise capacity, respiratory muscle function, and quality of life. The respective roles of transplantation and lung volume reduction surgery as therapies for advanced disease will be outlined.
Collapse
Affiliation(s)
- Namrata Patel
- Division of Pulmonary and Critical Care Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA.
| | | |
Collapse
|
11
|
|
12
|
Patel NM, Lederer DJ, Borczuk AC, Kawut SM. Pulmonary hypertension in idiopathic pulmonary fibrosis. Chest 2007; 132:998-1006. [PMID: 17873194 DOI: 10.1378/chest.06-3087] [Citation(s) in RCA: 182] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is an untreatable diffuse parenchymal lung disease with a median survival of < 3 years. Pulmonary hypertension (PH) is frequently seen in patients with IPF and is commonly attributed to hypoxic vasoconstriction and capillary destruction. Pathology findings include endothelial proliferation and medial hypertrophy that exceed those expected in the setting of hypoxia. Noninvasive evaluation has limited sensitivity and specificity for the diagnosis of PH in IPF; therefore, right-heart catheterization remains the "gold standard" diagnostic test. PH in patients with IPF is associated with decreased exercise capacity and worse survival. Given the grave consequences of this condition, treatment of PH could improve functional outcomes and survival. However, possible treatments such as long-term supplemental oxygen and targeted vascular therapy are either unstudied or remain unproven.
Collapse
Affiliation(s)
- Nina M Patel
- Department of Medicine, Division of Pulmonary, Allergy & Critical Care, Columbia University, 622 W 168th St, PH 8 East, Room 101, New York, NY 10032, USA.
| | | | | | | |
Collapse
|
13
|
Fattori R, Tricoci P, Russo V, Lovato L, Bacchi-Reggiani L, Gavelli G, Branzi A, Boriani G. Quantification of fatty tissue mass by magnetic resonance imaging in arrhythmogenic right ventricular dysplasia. J Cardiovasc Electrophysiol 2005; 16:256-61. [PMID: 15817082 DOI: 10.1046/j.1540-8167.2004.40498.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Arrhythmogenic right ventricular dysplasia (ARVD) is a heart muscle disorder in which the pathological substrate is a fatty or fibro-fatty replacement of the right ventricular (RV) myocardium. METHODS AND RESULTS Magnetic resonance imaging (MRI) studies were performed in 10 patients with arrhythmogenic right ventricular dysplasia and in 24 matched controls in order to assess right ventricular epicardial/intramyocardial fatty tissue mass, RV myocardial mass, and RV functional parameters. Functional abnormalities were found in all ARVD cases. Patients with ARVD showed increased fatty tissue compared to controls (8.2 +/- 4 g vs. 2.0 +/- 1.0 g; P = 0.001), whereas no significant differences were found in RV myocardial mass (29.5 +/- 9.2 g vs. 23.2 +/- 6.7 g; P = NS). A correlation coefficient between 0.87 and 0.97 was found for repeated measurements. CONCLUSION Quantification of fatty tissue with MRI is feasible and constitutes an objective method for differentiating normal from pathological conditions. This approach may lead to a complete diagnostic assessment of ARVD with the potential application for monitoring the evolution of the disease.
Collapse
Affiliation(s)
- Rossella Fattori
- Department of Radiology, University Hospital S. Orsola-Malpighi, Bologna, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Abstract
Interstitial lung disease is a heterogeneous group of illnesses, some of which may progress to a fibrosing stage and cause respiratory failure. For selected candidates, lung transplantation is the ultimate therapeutic option. We review data on lung transplantation for various interstitial lung diseases. We address indications, procedures, and outcomes for patients undergoing transplantation. Unique issues affecting morbidity, mortality, and recurrence of disease are discussed. We review the literature of transplantation for specific interstitial lung diseases and the outcomes of transplantation for interstitial lung diseases. Candidates with idiopathic pulmonary fibrosis experience high mortality on the waiting list, but derive significant survival benefit from lung transplantation. Recurrence is reported for several interstitial lung diseases after lung transplantation. Survival with lung transplantation for interstitial lung diseases is comparable with that attained in recipients with other indications. Lung transplantation is a well-tolerated, effective therapy for respiratory failure in interstitial lung disease.
Collapse
Affiliation(s)
- R Sulica
- Mount Sinai School of Medicine, One Gustave Levy Place, New York, NY 10029, USA
| | | | | |
Collapse
|
15
|
Abstract
Lung transplantation is able to provide dramatic gains in pulmonary function to patients with advanced pulmonary emphysema. At the present time, however, transplantation is available to a strictly defined pool of candidates, and outcomes are limited by numerous respiratory and nonrespiratory postoperative complications. Further progress is needed in expanding the supply of donor lungs, minimizing perioperative complications, and optimizing postoperative immunologic management.
Collapse
Affiliation(s)
- L L Schulman
- Department of Medicine, Lung Transplant Service, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.
| |
Collapse
|
16
|
Bîrsan T, Kranz A, Mares P, Artemiou O, Taghavi S, Zuckermann A, Klepetko W. Transient left ventricular failure following bilateral lung transplantation for pulmonary hypertension. J Heart Lung Transplant 1999; 18:304-9. [PMID: 10226894 DOI: 10.1016/s1053-2498(98)00050-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Bilateral lung transplantation is an established therapy for end-stage pulmonary hypertension. Its early postoperative outcome may be biased by various complications resulting in unexpected deterioration of the patient in terms of hemodynamics and blood gases. METHODS We have reviewed the early postoperative course of patients who underwent bilateral lung transplantation for pulmonary hypertension at our institution and analyzed all available data, especially hemodynamic measurements, echocardiographic documentation and therapeutical strategies, in those cases where cardiac dysfunction was found to be responsible for clinical deterioration. RESULTS Three out of 20 lung transplant recipients operated for pulmonary hypertension experienced severe respiratory insufficiency accompanied by hemodynamic decompensation during the first days after surgery. Clinical and laboratory findings together with results of echocardiography and pulmonary artery catheterism helped establish the diagnosis of left ventricular failure. This proved to be transitory, but the response to therapy (inotropic drugs, afterload reduction and eventually prostaglandins) was very variable. Adequately treated, this complication did not preclude the outcome of transplantation by itself. CONCLUSION Left ventricular failure is a possible complication after lung transplantation for pulmonary hypertension. Echocardiography and pulmonary artery catheterism may be useful adjuvant diagnostic tools, beside routine physical examination, chest X-ray, and laboratory analysis. Therapy of this complication must be adapted individually and may be complex.
Collapse
Affiliation(s)
- T Bîrsan
- Department of Cardiothoracic Surgery, University of Vienna, Austria
| | | | | | | | | | | | | |
Collapse
|
17
|
Quaife RA, Lynch D, Badesch DB, Voelkel NF, Lowes BD, Robertson AD, Bristow MR. Right ventricular phenotypic characteristics in subjects with primary pulmonary hypertension or idiopathic dilated cardiomyopathy. J Card Fail 1999; 5:46-54. [PMID: 10194660 DOI: 10.1016/s1071-9164(99)90024-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Studies of animal models and human subjects with cardiomyopathies suggest that cardiac myocyte and ventricular chamber remodeling show distinct phenotypic characteristics that may be dependent on specific signaling pathways. METHODS AND RESULTS In this study, we characterize right ventricular (RV) chamber size, end-diastolic thickness, myocardial mass, and ejection fraction (EF) in human subjects with chronic heart failure from primary pulmonary hypertension (PPH; n = 10) and idiopathic dilated cardiomyopathy (IDC; n = 10). Subjects underwent gated cardiac magnetic resonance imaging (MRI), and the RVs were phenotypically classified based on the presence or absence of hypertrophy (increased mass), systolic dysfunction (reduced EF), and degree of wall thickness (concentric v eccentric pattern of hypertrophy). Within this schema, five abnormal phenotypes could be identified. In PPH subjects, in whom the RV is subjected to the uniform insult of chronic pressure overload, four different abnormal phenotypes were identified. CONCLUSIONS These data indicate that distinct structural/functional ventricular chamber phenotypes may be classified by MRI, and that a uniform insult can result in multiple RV phenotypes.
Collapse
Affiliation(s)
- R A Quaife
- Department of Medicine, University of Colorado Health Sciences Center, Denver 80262, USA
| | | | | | | | | | | | | |
Collapse
|
18
|
Mal H, Levy A, Laperche T, Sleiman C, Stievenart JL, Cohen-Solal A, Brugière O, Lesèche G, Jebrak G, Fournier M. Limitations of radionuclide angiographic assessment of left ventricular systolic function before lung transplantation. Am J Respir Crit Care Med 1998; 158:1396-402. [PMID: 9817685 DOI: 10.1164/ajrccm.158.5.9710046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
To evaluate the influence of increased right ventricular afterload on radionuclide assessment of the left ventricular ejection fraction (LVEF), we compared the preoperative and postoperative value of isotopic LVEF in 11 patients who underwent lung transplantation and had a preoperative LVEF value below 55% (normal value: 68 +/- 8%). The underlying disease conditions were obstructive lung disease (n = 7) and pulmonary fibrosis (n = 4). The transplantation procedure was unilateral in 10 patients and bilateral in one. The mean value of isotopic LVEF prior to transplantation was 51 +/- 3% (range: 49% to 55%). At 42 +/- 13 mo postoperatively, isotopic LVEF increased significantly, to 65 +/- 10% (p = 0.001), suggesting that intrinsic left ventricular systolic function was in fact normal in these patients. We hypothesize that the low preoperative isotopic LEVF was not related to intrinsic dysfunction of the left ventricle, but rather to right ventricular pressure overload, leading to bulging of the interventricular septum into the left ventricle and to subsequent geometric distortion of the left ventricle. We conclude that isotopic LVEF may underestimate intrinsic left-ventricular systolic function in patients with severe chronic lung disease. Candidates for lung transplantation should not be rejected on the basis of a low isotopic LVEF, provided echocardiographic examination does show apparently normal left ventricular contraction.
Collapse
Affiliation(s)
- H Mal
- Services de Pneumologie et Réanimation Respiratoire, Cardiologie, Chirurgie Thoracique et Vasculaire, and Médecine Nucléaire, Hôpital Beaujon, Clichy, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Henk CB, Schlechta B, Grampp S, Gomischek G, Klepetko W, Mostbeck GH. Pulmonary and aortic blood flow measurements in normal subjects and patients after single lung transplantation at 0.5 T using velocity encoded cine MRI. Chest 1998; 114:771-9. [PMID: 9743165 DOI: 10.1378/chest.114.3.771] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
PURPOSE It is the purpose of this study to compare pulmonary and aortic blood flow measurements obtained in patients after single lung transplantation (SLTX) with those in volunteers. METHODS/MATERIAL: In nine patients after SLTX (three male, six female) and nine volunteers (seven male, two female), double oblique phase contrast cine-MRI sequences perpendicular to the direction of blood flow were obtained in the ascending aorta, main, right, and left pulmonary artery on a 0.5-T unit (Philips Gyroscan; Best, the Netherlands) (repetition time, 600 to 800 ms; echo time, 8 ms; alpha=30; field of view=280 mm matrix, 128x256, ECG gating, temporal resolution 16 time frames/RR interval). An initial in vitro study using the same sequence on a nonpulsatile flow phantom showed excellent correlation (r=0.99) between MRI measurements of flow velocity and flow volume and true velocity and flow volume. Measurements of blood flow volume (mL/min), peak mean systolic velocity, resistive index, and distensibility index were obtained in each vessel. RESULTS We found excellent correlations between left and right cardiac output as measured by velocity encoded cine-MRI (VEC-MRI) in the ascending aorta and main pulmonary artery both in normal volunteers (r=0.95) and in patients (r=0.91). Differential pulmonary blood flow measurements in volunteers showed that 55% of the right cardiac output was directed to the right and 45% to the left lung. Differential pulmonary blood flow in patients showed that most of the blood flow (81%) reaches the transplanted lung and only 19% reaches the patient's own lung (SLTX: 4.5+/-1.8 L/min, patient's own lung: 1.2+/-0.8 L/min). There were significant differences (p<0.05) in peak mean systolic velocity and resistive index obtained in the pulmonary arteries, both between normal volunteers and patients and between measurements obtained in the patient's own lung and the transplanted lung. CONCLUSION VEC-MRI blood flow measurements are a promising noninvasive tool to monitor the hemodynamic changes of pulmonary blood flow after SLTX.
Collapse
Affiliation(s)
- C B Henk
- Department of Radiology, Ludwig Boltzmann Institute for Physical and Radiological Tumor Diagnosis, University of Vienna, Austria
| | | | | | | | | | | |
Collapse
|
20
|
Bristow MR, Zisman LS, Lowes BD, Abraham WT, Badesch DB, Groves BM, Voelkel NF, Lynch DM, Quaife RA. The pressure-overloaded right ventricle in pulmonary hypertension. Chest 1998; 114:101S-106S. [PMID: 9676654 DOI: 10.1378/chest.114.1_supplement.101s] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- M R Bristow
- Division of Cardiology, University of Colorado Health Science Center, Denver, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Stiebellehner L, Quittan M, End A, Wieselthaler G, Klepetko W, Haber P, Burghuber OC. Aerobic endurance training program improves exercise performance in lung transplant recipients. Chest 1998; 113:906-12. [PMID: 9554624 DOI: 10.1378/chest.113.4.906] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
STUDY OBJECTIVE To determine whether an aerobic endurance training program (AET) in comparison to normal daily activities improves exercise capacity in lung transplant recipients. PATIENTS AND STUDY DESIGN Nine lung transplant recipients (12+/-6 months after transplant) were examined. All patients underwent incremental bicycle ergometry with the work rate increased in increments of 20 W every 3 min. Identical exercise tests were performed after 11+/-5 weeks of normal daily activities and then after a 6-week AET. The weekly aerobic training time increased from 60 min at the beginning to 120 min during the last week. Training intensity ranged from 30 to 60% of the maximum heart rate reserve. RESULTS Normal daily activities had no effect on exercise performance. The AET induced a significant decrease in resting minute ventilation from 14+/-5 to 11+/-3 L/min. At an identical, submaximal level of exercise, a significant decrease in minute ventilation from 47+/-14 L/min to 39+/-13 L/min and heart rate from 144+/-12 to 133+/-17 beats/min, before and after the AET, was noted. The increase in peak oxygen uptake after AET was statistically significant (1.13+/-0.32 to 1.26+/-0.27 L/min). CONCLUSIONS These data demonstrate that normal daily activities do not affect exercise performance in lung transplant recipients > or = 6 months after lung transplantation. An AET improves submaximal and peak exercise performance significantly.
Collapse
|
22
|
Wekerle T, Klepetko W, Taghavi S, Birsan T. Lung transplantation for primary pulmonary hypertension and giant pulmonary artery aneurysm. Ann Thorac Surg 1998; 65:825-7. [PMID: 9527223 DOI: 10.1016/s0003-4975(97)01413-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We report the case of an 18-year-old patient with a giant pulmonary artery aneurysm and primary pulmonary hypertension who was successfully treated with bilateral lung transplantation and complete reconstruction of the pulmonary artery.
Collapse
Affiliation(s)
- T Wekerle
- Department of Cardiothoracic Surgery, University of Vienna, Vienna General Hospital, Austria
| | | | | | | |
Collapse
|
23
|
Globits S, Kreiner G, Frank H, Heinz G, Klaar U, Frey B, Gössinger H. Significance of morphological abnormalities detected by MRI in patients undergoing successful ablation of right ventricular outflow tract tachycardia. Circulation 1997; 96:2633-40. [PMID: 9355904 DOI: 10.1161/01.cir.96.8.2633] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND MRI can demonstrate subtle morphological changes of the right ventricle in patients with idiopathic right ventricular outflow tract tachycardia (RVOT). The present study examines the incidence and significance of right ventricular (RV) abnormalities detected by MRI with respect to the site of successful radiofrequency catheter ablation of the clinical tachycardia. METHODS AND RESULTS The study population comprised 20 patients (mean age, 40+/-12 years) undergoing elimination of recurrent RVOT by radiofrequency catheter ablation. MRI studies were performed before ablation to assess RV volumes and function, as well as structural abnormalities of the RV myocardium. Ten healthy age- and sex-matched subjects served as control subjects. The successful ablation sites, as documented by radiographs of the catheter position, were compared with MRI findings. Patients with RVOT showed no difference in respect to RV volumes and ejection fractions compared with control subjects. Whereas RV abnormalities were limited to prominent fatty deposits of the right atrioventricular groove extending into the inlet portion of the RV wall in 2 of 10 control subjects, MRI studies demonstrated morphological changes of the RV free wall in 13 (65%) of 20 patients with RVOT, including presence of fatty tissue (n=5), wall thinning (n=9), and dyskinetic wall segments (n=4). Eight of these patients had additional fat deposits, thinning, or a saccular aneurysm in the RV outflow tract, corresponding with the ablation site in 6 patients. CONCLUSIONS In RVOT, structural abnormalities of the right ventricle can be detected in a substantial number of patients despite normal RV volumes and global function. MRI abnormalities within the RV outflow tract are significantly associated with the origin of tachycardia.
Collapse
Affiliation(s)
- S Globits
- 2nd Department of Internal Medicine, University of Vienna, Austria
| | | | | | | | | | | | | |
Collapse
|
24
|
Williams TJ, Snell GI. Early and long-term functional outcomes in unilateral, bilateral, and living-related transplant recipients. Clin Chest Med 1997; 18:245-57. [PMID: 9187819 DOI: 10.1016/s0272-5231(05)70376-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Lung transplantation offers the possibility of improved quality of life and survival in patients with severe pulmonary and pulmonary vascular disease. Since the first human lung allotransplantation in 1963, survival has moved from hours or days into the present era of long-term (years) survival in many recipients. Measurement of outcome has now extended to measurement of exercise capacity and quality of life. A substantial improvement in quality of life is seen; however, exercise capacity remains moderately impaired in spite of the return (in many) of near normal cardiopulmonary function, suggesting peripheral limitation to exercise. Recently, fiber type changes and abnormal oxidative metabolism have been shown in the skeletal muscle of stable lung transplant recipients. This suggests a persistence of a pretransplant skeletal muscle injury and/ or the effects of post-transplant immunosuppression (particularly Cyclosporin A and corticosteroids).
Collapse
Affiliation(s)
- T J Williams
- Lung Transplant Service (Medical), Alfred Hospital, Victoria, Australia
| | | |
Collapse
|
25
|
Bracken CA, Gurkowski MA, Naples JJ. Lung transplantation: historical perspective, current concepts, and anesthetic considerations. J Cardiothorac Vasc Anesth 1997; 11:220-41. [PMID: 9105999 DOI: 10.1016/s1053-0770(97)90220-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- C A Bracken
- Department of Anesthesiology, University of Texas Health Science Center in San Antonio 78284-7838, USA
| | | | | |
Collapse
|
26
|
Casalino E, Laissy JP, Soyer P, Bouvet E, Vachon F. Assessment of right ventricle function and pulmonary artery circulation by cine-MRI in patients with AIDS. Chest 1996; 110:1243-7. [PMID: 8915228 DOI: 10.1378/chest.110.5.1243] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To evaluate right ventricle (RV) anatomy and performance and its relationships with pulmonary circulation in AIDS patients. DESIGN We conducted a prospective blinded study by using cine-MRI, a well-accepted method to assess RV and pulmonary circulation. SETTING A university hospital. PARTICIPANTS Ten healthy volunteers and 13 asymptomatic AIDS patients. MEASUREMENTS RV end-diastolic and end-systolic volumes, RV ejection fraction (RVEF), pulmonary artery (PA) diameter, main pulmonary artery distensibility (MPAD), RV free wall diastolic thickness (RVWT), and RV mass were measured. The RVWT/left ventricular wall thickness index was calculated. RESULTS AIDS patients had significantly increased RV end-diastolic and end-systolic volumes and decreased RVEF (50 +/- 10 vs 59 +/- 6; p < 0.03). Four AIDS patients had RV wall motion abnormalities; 5 (38%) had an RVEF under 45%. RVWT, the RVWT/left ventricular wall thickness index, and PA diameter were significantly increased in AIDS patients. RV mass was increased in 54% of AIDS patients. MPAD was significantly lower in AIDS patients (18.8 +/- 15 vs 26 +/- 4; p < 0.01). A significant relationship was found between RV mass and MPAD (r = 0.76; p = 0.02). CONCLUSIONS RV function is frequently impaired in AIDS patients. Anatomic and functional abnormalities found in RV and PA parameters suggest a systolic overload on RV. Pulmonary circulation abnormalities may influence RV structure and function in AIDS patients.
Collapse
Affiliation(s)
- E Casalino
- Infectious Disease Intensive Care Unit, Bichat-Claude Bernard University Hospital, Paris, France
| | | | | | | | | |
Collapse
|
27
|
Abstract
Various methods of Doppler echocardiography are useful in the analysis of flow dynamics within the heart and the pulmonary circulation in patients with COPD. In addition, to distinguish patients with increased pulmonary artery pressures from those with normal pressures, Doppler techniques provide quantitative methods for estimating pulmonary artery pressures non-invasively. Doppler echocardiography can be performed repeatedly and can thus be used to assess serial changes in the clinical state of a patient or in the response to certain pharmaceutical interventions in the pulmonary vascular bed. The most useful and accurate method of estimating pulmonary artery pressures in patients with chronic hypoxic lung disease is the systolic trans-tricuspid gradient, calculated from tricuspid regurgitation detected by continuous wave Doppler echocardiography with estimation of the right ventricular pressure, followed by the acceleration time from pulmonary flow analysis using pulsed Doppler techniques. New contrast materials to enhance the continuous wave Doppler signal and transoesophageal echocardiography may provide even more satisfactory results in the future.
Collapse
|
28
|
Pulmonale Thrombendarterektomie: Die Therapie der chronisch thromboembolischen pulmonalen Hypertension— Initiale chirurgische Erfahrung. Eur Surg 1995. [DOI: 10.1007/bf02602274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|