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Mattei A, Strumia A, Benedetto M, Nenna A, Schiavoni L, Barbato R, Mastroianni C, Giacinto O, Lusini M, Chello M, Carassiti M. Perioperative Right Ventricular Dysfunction and Abnormalities of the Tricuspid Valve Apparatus in Patients Undergoing Cardiac Surgery. J Clin Med 2023; 12:7152. [PMID: 38002763 PMCID: PMC10672350 DOI: 10.3390/jcm12227152] [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: 10/07/2023] [Revised: 11/03/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
Right ventricular (RV) dysfunction frequently occurs after cardiac surgery and is linked to adverse postoperative outcomes, including mortality, reintubation, stroke, and prolonged ICU stays. While various criteria using echocardiography and hemodynamic parameters have been proposed, a consensus remains elusive. Distinctive RV anatomical features include its thin wall, which presents a triangular shape in a lateral view and a crescent shape in a cross-sectional view. Principal causes of RV dysfunction after cardiac surgery encompass ischemic reperfusion injury, prolonged ischemic time, choice of cardioplegia and its administration, cardiopulmonary bypass weaning characteristics, and preoperative risk factors. Post-left ventricular assist device (LVAD) implantation RV dysfunction is common but often transient, with a favorable prognosis upon resolution. There is an ongoing debate regarding the benefits of concomitant surgical repair of the RV in the presence of regurgitation. According to the literature, the gold standard techniques for assessing RV function are cardiac magnetic resonance imaging and hemodynamic assessment using thermodilution. Echocardiography is widely favored for perioperative RV function evaluation due to its accessibility, reproducibility, non-invasiveness, and cost-effectiveness. Although other techniques exist for RV function assessment, they are less common in clinical practice. Clinical management strategies focus on early detection and include intravenous drugs (inotropes and vasodilators), inhalation drugs (pulmonary vasodilators), ventilator strategies, volume management, and mechanical support. Bridging research gaps in this field is crucial to improving clinical outcomes associated with RV dysfunction in the near future.
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Affiliation(s)
- Alessia Mattei
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Alessandro Strumia
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Maria Benedetto
- Cardio-Thoracic and Vascular Anesthesia and Intesive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40123 Bologna, Italy;
| | - Antonio Nenna
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Lorenzo Schiavoni
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
| | - Raffaele Barbato
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Ciro Mastroianni
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Omar Giacinto
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Mario Lusini
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Massimo Chello
- Cardiac Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Massimiliano Carassiti
- Anesthesia and Intensive Care Operative Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy; (A.M.); (A.S.); (L.S.)
- Anesthesia and Intensive Care Research Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
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Radel LJ, Iqbal M, Griffiths M. Intravenous prostacyclins for right ventricular failure following left ventricular assist device in paediatric heart failure. Cardiol Young 2023; 33:2422-2424. [PMID: 37381831 DOI: 10.1017/s1047951123001725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Right ventricular failure after placement of left ventricular assist device in paediatric heart failure is associated with increased mortality. We report successful use of intravenous prostacyclin for right ventricular support and pulmonary hypertension after initiation of left ventricular assist device support. This suggests that intravenous prostacyclins may be an important therapy in right ventricular failure following ventricular assist device implantation.
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Affiliation(s)
- Laura J Radel
- Division of Cardiology, Department of Paediatrics, University of Texas Southwestern, Dallas, TX, USA
| | - Mehreen Iqbal
- Division of Cardiology, Department of Paediatrics, University of Texas Southwestern, Dallas, TX, USA
| | - Megan Griffiths
- Division of Cardiology, Department of Paediatrics, University of Texas Southwestern, Dallas, TX, USA
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Belhaj A, Dewachter L, Hupkens E, Remmelink M, Galanti L, Rorive S, Melot C, Naeije R, Rondelet B. Tacrolimus Prevents Mechanical and Humoral Alterations in Brain Death-Induced Lung Injury in Pigs. Am J Respir Crit Care Med 2022; 206:584-595. [PMID: 35549669 DOI: 10.1164/rccm.202201-0033oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Donor brain death-induced lung injury may compromise graft function after transplantation. Establishing strategies to attenuate lung damage remains a challenge because the underlying mechanisms remain uncertain. OBJECTIVES The effects of tacrolimus pretreatment were evaluated in an experimental model of brain death-induced lung injury. METHODS Brain death was induced by slow intracranial infusion of blood in anesthetized pigs after randomization to tacrolimus (orally administered at 0.25 mg. kg-1 BID the day before the experiment and intravenously at 0.05 mg. kg-1 one hour before the experiment; n=8) or placebo (n=9) pretreatment. Hemodynamic measurements were performed 1, 3, 5 and 7 hours after brain death. After euthanasia of the animals, lung tissue was sampled for pathobiological and histological analysis, including lung injury scoring (LIS). MEASUREMENTS AND MAIN RESULTS Tacrolimus pretreatment prevented increases in pulmonary artery pressure, pulmonary vascular resistance and pulmonary capillary pressure and decreases in systemic artery pressure and thermodilution cardiac output associated with brain death. After brain death, the ratio of the partial arterial O2 pressure to the inspired O2 fraction (PaO2/FiO2) decreased, which was prevented by tacrolimus. Tacrolimus pretreatment prevented increases in the interleukin (IL)-6-to-IL-10 ratio, vascular cell adhesion molecule-1, circulating levels of IL-1β, IL-6-to-IL-10 ratio and glycocalyx-derived molecules. Tacrolimus partially decreased apoptosis [Bax-to-Bcl2 ratio (p=0.07) and the number of apoptotic cells in the lungs (p<0.05)] but failed to improve LIS. CONCLUSIONS Immunomodulation through tacrolimus pretreatment prevented pulmonary capillary hypertension as well as the activation of inflammatory and apoptotic processes in the lungs after brain death; however, LIS did not improve.
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Affiliation(s)
- Asmae Belhaj
- CHU UCL Namur, 82470, cardiovascular, thoracic surgery and lung transplantation, Yvoir, Belgium.,Université Libre de Bruxelles, 26659, Laboratory of Physiology and Pharmacology, Faculty of Medicine, Bruxelles, Belgium;
| | - Laurence Dewachter
- Université Libre de Bruxelles, 26659, Laboratory of Physiology and Pharmacology, Faculty of Medicine, Bruxelles, Belgium
| | - Emeline Hupkens
- Université Libre de Bruxelles, 26659, Laboratory of Physiology and Pharmacology, Faculty of Medicine, Bruxelles, Belgium
| | - Myriam Remmelink
- Université Libre de Bruxelles, 26659, Department of Pathology, Hôpital Erasme, Brussels, Belgium
| | - Laurence Galanti
- CHU UCL Namur, 82470, Department of Clinical Biology, Yvoir, Belgium
| | - Sandrine Rorive
- Université Libre de Bruxelles, 26659, Department of Pathology, Hôpital Erasme, Brussels, Belgium
| | - Christian Melot
- Université Libre de Bruxelles, 26659, Laboratory of Physiology and Pharmacology, Faculty of Medicine, Bruxelles, Belgium
| | - Robert Naeije
- Department of Pathophysiology, Free University of Brussels, Brussels, Belgium
| | - Benoît Rondelet
- CHU UCL Namur, 82470, cardiovascular, thoracic surgery and lung transplantation, Yvoir, Belgium.,Université Libre de Bruxelles, 26659, Laboratory of Physiology and Pharmacology, Faculty of Medicine, Bruxelles, Belgium
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Reversal of Right Ventricular Hypertrophy and Dysfunction by Prostacyclin in a Rat Model of Severe Pulmonary Arterial Hypertension. Int J Mol Sci 2022; 23:ijms23105426. [PMID: 35628236 PMCID: PMC9141343 DOI: 10.3390/ijms23105426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 12/04/2022] Open
Abstract
Prostacyclin analogs are among the most effective and widely used therapies for pulmonary arterial hypertension (PAH). However, it is unknown whether they also confer protection through right ventricle (RV) myocardio-specific mechanisms. Moreover, the use of prostacyclin analogs in severe models of PAH has not been adequately tested. To further identify underlying responses to prostacyclin, a prostacyclin analogue, treprostinil, was used in a preclinical rat Sugen-chronic hypoxia (SuCH) model of severe PAH that closely resembles the human disease. Male Sprague–Dawley rats were implanted with osmotic pumps containing vehicle or treprostinil, injected concurrently with a bolus of Sugen (SU5416) and exposed to 3-week hypoxia followed by 3-week normoxia. RV function was assessed using pressure–volume loops and hypertrophy by weight assessed. To identify altered mechanisms within the RV, tissue samples were used to perform a custom RNA array analysis, histological staining, and protein and transcript level confirmatory analyses. Treprostinil significantly reduced SuCH-associated RV hypertrophy and decreased the rise in RV systolic pressure, mean pulmonary arterial (mPAP), and right atrial (RAP) pressure. Prostacyclin treatment was associated with improvements in RV stroke work, maximum rate of ventricular pressure change (max dP/dt) and the contractile index, and almost a complete reversal of SuCH-associated increase in RV end-systolic elastance, suggesting the involvement of load-independent improvements in intrinsic RV systolic contractility by prostacyclin treatment. An analysis of the RV tissues showed no changes in cardiac mitochondrial respiration and ATP generation. However, custom RNA array analysis revealed amelioration of SuCH-associated increases in newly identified TBX20 as well as the fibrotic markers collagen1α1 and collagen 3α1 upon treprostinil treatment. Taken together, our data support decreased afterload and load-independent improvements in RV function following prostacyclin administration in severe PAH, and these changes appear to associate with improvements in RV fibrotic responses.
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Tello K, Kremer N, Richter MJ, Gall H, Muenks J, Ghofrani A, Schermuly R, Naeije R, Kojonazarov B, Seeger W. Inhaled Iloprost Improves Right Ventricular Load-Independent Contractility in Pulmonary Hypertension. Am J Respir Crit Care Med 2022; 206:111-114. [PMID: 35426780 DOI: 10.1164/rccm.202201-0095le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Khodr Tello
- University Hospital Giessen und Marburg GmbH, Pulmonary Hypertension Division, Medical Clinic II, Giessen, Germany
| | - Nils Kremer
- University Hospital Giessen, Giessen, Germany
| | - Manuel J Richter
- University Hospital Giessen und Marburg GmbH, Pulmonary Hypertension Division, Medical Clinic II, Giessen, Germany
| | - Henning Gall
- University Hospital Giessen und Marburg GmbH, Pulmonary Hypertension Division, Medical Clinic II, Giessen, Germany
| | - Jonas Muenks
- University Hospitals Giessen and Marburg Campus Giessen, 14973, Giessen, Germany
| | - Ardeschir Ghofrani
- University Hospitals Giessen and Marburg Campus Giessen, 14973, Giessen, Germany
| | - Ralph Schermuly
- Justus-Leibig-University, Internal Medicine, Giessen, Germany
| | | | | | - Werner Seeger
- Justus Liebig University, Internal Medicine, Giessen, Germany
- Max-Planck-Institute for Heart and Lung Research, Department of Lung Development and Remodeling, Bad Nauheim, Germany
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Wang L, Halliday G, Huot JR, Satoh T, Baust JJ, Fisher A, Cook T, Hu J, Avolio T, Goncharov DA, Bai Y, Vanderpool RR, Considine RV, Bonetto A, Tan J, Bachman TN, Sebastiani A, Mora AL, Machado RF, Goncharova EA, Gladwin MT, Lai YC. Treatment With Treprostinil and Metformin Normalizes Hyperglycemia and Improves Cardiac Function in Pulmonary Hypertension Associated With Heart Failure With Preserved Ejection Fraction. Arterioscler Thromb Vasc Biol 2020; 40:1543-1558. [PMID: 32268788 PMCID: PMC7255946 DOI: 10.1161/atvbaha.119.313883] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Pulmonary hypertension (PH) due to left heart disease (group 2), especially in the setting of heart failure with preserved ejection fraction (HFpEF), is the most common cause of PH worldwide; however, at present, there is no proven effective therapy available for its treatment. PH-HFpEF is associated with insulin resistance and features of metabolic syndrome. The stable prostacyclin analog, treprostinil, is an effective and widely used Food and Drug Administration-approved drug for the treatment of pulmonary arterial hypertension. While the effect of treprostinil on metabolic syndrome is unknown, a recent study suggests that the prostacyclin analog beraprost can improve glucose intolerance and insulin sensitivity. We sought to evaluate the effectiveness of treprostinil in the treatment of metabolic syndrome-associated PH-HFpEF. Approach and Results: Treprostinil treatment was given to mice with mild metabolic syndrome-associated PH-HFpEF induced by high-fat diet and to SU5416/obese ZSF1 rats, a model created by the treatment of rats with a more profound metabolic syndrome due to double leptin receptor defect (obese ZSF1) with a vascular endothelial growth factor receptor blocker SU5416. In high-fat diet-exposed mice, chronic treatment with treprostinil reduced hyperglycemia and pulmonary hypertension. In SU5416/Obese ZSF1 rats, treprostinil improved hyperglycemia with similar efficacy to that of metformin (a first-line drug for type 2 diabetes mellitus); the glucose-lowering effect of treprostinil was further potentiated by the combined treatment with metformin. Early treatment with treprostinil in SU5416/Obese ZSF1 rats lowered pulmonary pressures, and a late treatment with treprostinil together with metformin improved pulmonary artery acceleration time to ejection time ratio and tricuspid annular plane systolic excursion with AMPK (AMP-activated protein kinase) activation in skeletal muscle and the right ventricle. CONCLUSIONS Our data suggest a potential use of treprostinil as an early treatment for mild metabolic syndrome-associated PH-HFpEF and that combined treatment with treprostinil and metformin may improve hyperglycemia and cardiac function in a more severe disease.
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Affiliation(s)
- Longfei Wang
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
- The Third Xiangya Hospital, Central South University; Changsha, Hunan, China
| | - Gunner Halliday
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
| | - Joshua R. Huot
- Department of Surgery, Indiana University School of Medicine
| | - Taijyu Satoh
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jeff J. Baust
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Amanda Fisher
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
| | - Todd Cook
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
| | - Jian Hu
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Theodore Avolio
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Dmitry A. Goncharov
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Yang Bai
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
- Department of Clinical Pharmacology, College of Pharmacy, China Medical University, Shenyang, Liaoning, China
| | | | | | - Andrea Bonetto
- Department of Surgery, Indiana University School of Medicine
| | - Jiangning Tan
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh
| | - Timothy N. Bachman
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Andrea Sebastiani
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Ana L. Mora
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh
| | - Roberto F. Machado
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
| | - Elena A. Goncharova
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh
| | - Mark T. Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh
| | - Yen-Chun Lai
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
- Department of Anatomy, Cell Biology & Physiology, Indiana University School of Medicine
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Tello K, Seeger W, Naeije R, Vanderpool R, Ghofrani HA, Richter M, Tedford RJ, Bogaard HJ. Right heart failure in pulmonary hypertension: Diagnosis and new perspectives on vascular and direct right ventricular treatment. Br J Pharmacol 2019; 178:90-107. [PMID: 31517994 DOI: 10.1111/bph.14866] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/15/2019] [Accepted: 09/04/2019] [Indexed: 12/18/2022] Open
Abstract
Adaptation of right ventricular (RV) function to increased afterload-known as RV-arterial coupling-is a key determinant of prognosis in pulmonary hypertension. However, measurement of RV-arterial coupling is a complex, invasive process involving analysis of the RV pressure-volume relationship during preload reduction over multiple cardiac cycles. Simplified methods have therefore been proposed, including echocardiographic and cardiac MRI approaches. This review describes the available methods for assessment of RV function and RV-arterial coupling and the effects of pharmacotherapy on these variables. Overall, pharmacotherapies for pulmonary hypertension have shown beneficial effects on various measures of RV function, but it is often unclear if these are direct RV effects or indirect results of afterload reduction. Studies of the effects of pharmacotherapies on RV-arterial coupling are limited and mostly restricted to experimental models. Simplified methods to assess RV-arterial coupling should be validated and incorporated into routine clinical follow-up and future clinical trials. LINKED ARTICLES: This article is part of a themed issue on Risk factors, comorbidities, and comedications in cardioprotection. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.1/issuetoc.
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Affiliation(s)
- Khodr Tello
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Robert Naeije
- Physiology, Erasme University Hospital, Brussels, Belgium
| | | | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Manuel Richter
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina (MUSC), Charleston, SC, USA
| | - Harm J Bogaard
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Lahm T, Douglas IS, Archer SL, Bogaard HJ, Chesler NC, Haddad F, Hemnes AR, Kawut SM, Kline JA, Kolb TM, Mathai SC, Mercier O, Michelakis ED, Naeije R, Tuder RM, Ventetuolo CE, Vieillard-Baron A, Voelkel NF, Vonk-Noordegraaf A, Hassoun PM. Assessment of Right Ventricular Function in the Research Setting: Knowledge Gaps and Pathways Forward. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2019; 198:e15-e43. [PMID: 30109950 DOI: 10.1164/rccm.201806-1160st] [Citation(s) in RCA: 203] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Right ventricular (RV) adaptation to acute and chronic pulmonary hypertensive syndromes is a significant determinant of short- and long-term outcomes. Although remarkable progress has been made in the understanding of RV function and failure since the meeting of the NIH Working Group on Cellular and Molecular Mechanisms of Right Heart Failure in 2005, significant gaps remain at many levels in the understanding of cellular and molecular mechanisms of RV responses to pressure and volume overload, in the validation of diagnostic modalities, and in the development of evidence-based therapies. METHODS A multidisciplinary working group of 20 international experts from the American Thoracic Society Assemblies on Pulmonary Circulation and Critical Care, as well as external content experts, reviewed the literature, identified important knowledge gaps, and provided recommendations. RESULTS This document reviews the knowledge in the field of RV failure, identifies and prioritizes the most pertinent research gaps, and provides a prioritized pathway for addressing these preclinical and clinical questions. The group identified knowledge gaps and research opportunities in three major topic areas: 1) optimizing the methodology to assess RV function in acute and chronic conditions in preclinical models, human studies, and clinical trials; 2) analyzing advanced RV hemodynamic parameters at rest and in response to exercise; and 3) deciphering the underlying molecular and pathogenic mechanisms of RV function and failure in diverse pulmonary hypertension syndromes. CONCLUSIONS This statement provides a roadmap to further advance the state of knowledge, with the ultimate goal of developing RV-targeted therapies for patients with RV failure of any etiology.
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Wang L, Zhu X, Zhao LP, Wang M, Liu X, Chen Y, Chen J, Xu W. Effect of beraprost on pulmonary hypertension due to left ventricular systolic dysfunction. Medicine (Baltimore) 2019; 98:e14965. [PMID: 31008926 PMCID: PMC6494404 DOI: 10.1097/md.0000000000014965] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Beraprost is used to treat peripheral chronic arterial occlusive disease. However, the efficacy and safety of beraprost in patients with pulmonary hypertension (PH) due to left ventricular systolic dysfunction (PH-HFrEF) remains unknown. The primary objective of this study was to determine the effects of beraprost on PH-HFrEF.We prospectively recruited patients with PH-HFrEF as determined by echocardiography and right cardiac catheterization. Beraprost sodium was given orally (1 μg/kg/d) added to the usual treatment, and patients were evaluated at 1-year follow-up.Twenty-five patients were recruited with baseline systolic pulmonary artery pressure (PAP) of 49.5 ± 10.8 mm Hg. Systolic PAP results at 3, 6, 9, and 12 months were 39.1 ± 8.1, 30.4 ± 5.2, 27.7 ± 3.0, and 27.0 ± 4.7 mm Hg, respectively, which were all significantly lower than systolic PAP at baseline (P < .05). Left ventricular ejection fraction results at 6 months (43.5 ± 7.0%), 9 months (47.0 ± 5.5%), and 12 months (48.2 ± 4.8%) were significantly higher than at baseline (34.7 ± 9.2%) (P < .05). Six-minute walking distance at 3 months (282.8 ± 80.6 m), 6 months (367.1 ± 81.2 m), 9 months (389.8 ± 87.1 m), and 12 months (395.7 ± 83.4 m) increased with time, and all were significantly higher than baseline (190.1 ± 75.5 m) (P < .05). One patient developed atrial fibrillation and recovered to sinus rhythm after intravenous administration of amiodarone. There were no instances of cardiac-related death, severe bleeding, or severe impairment of liver function.Routine oral administration of beraprost sodium added to the usual treatment may improve cardiopulmonary hemodynamics and exercise capacityin patients with PH-HFrEF.
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Affiliation(s)
- Li Wang
- Department of Cardiology, The Second Affiliated Hospital of Soochow University
- Emergency Department, The Seventh People's Hospital of Suzhou, China
| | - Xinyi Zhu
- Department of Cardiology, The Second Affiliated Hospital of Soochow University
| | - Liang-Ping Zhao
- Department of Cardiology, The Second Affiliated Hospital of Soochow University
| | - Maosong Wang
- Department of Cardiology, The Second Affiliated Hospital of Soochow University
| | - Xiang Liu
- Department of Cardiology, The Second Affiliated Hospital of Soochow University
| | - Yuqi Chen
- Department of Cardiology, The Second Affiliated Hospital of Soochow University
| | - JianChang Chen
- Department of Cardiology, The Second Affiliated Hospital of Soochow University
| | - WeiTing Xu
- Department of Cardiology, The Second Affiliated Hospital of Soochow University
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Abstract
The most common cause of right heart failure is increased afterload caused by pulmonary hypertension. Right ventricular function adaptation to increased afterload is basically systolic, with secondary increase in dimensions and systemic congestion. Increased right ventricular dimensions and decreased ejection fraction are associated with a decreased survival in severe pulmonary hypertension. Targeted therapies titrated to reverse the right ventricular remodeling dimensions improve survival in severe pulmonary hypertension.
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Tabima DM, Philip JL, Chesler NC. Right Ventricular-Pulmonary Vascular Interactions. Physiology (Bethesda) 2018; 32:346-356. [PMID: 28814495 DOI: 10.1152/physiol.00040.2016] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 06/16/2017] [Accepted: 07/06/2017] [Indexed: 11/22/2022] Open
Abstract
Accurate and comprehensive evaluation of right ventricular (RV)-pulmonary vascular (PV) interactions is critical to the assessment of cardiopulmonary function, dysfunction, and failure. Here, we review methods of quantifying RV-PV interactions and experimental results from clinical trials as well as large- and small-animal models based on pressure-volume analysis. We conclude by outlining critical gaps in knowledge that should drive future studies.
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Affiliation(s)
- Diana M Tabima
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, Wisconsin; and
| | - Jennifer L Philip
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, Wisconsin; and.,Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| | - Naomi C Chesler
- Department of Biomedical Engineering, University of Wisconsin-Madison College of Engineering, Madison, Wisconsin; and
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Boehm M, Lawrie A, Wilhelm J, Ghofrani HA, Grimminger F, Weissmann N, Seeger W, Schermuly RT, Kojonazarov B. Maintained right ventricular pressure overload induces ventricular-arterial decoupling in mice. Exp Physiol 2018; 102:180-189. [PMID: 27990701 DOI: 10.1113/ep085963] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 11/28/2016] [Indexed: 12/14/2022]
Abstract
NEW FINDINGS What is the central question of this study? The aim was to investigate whether complementary assessment of non-invasive ultrasound imaging together with closed chest-derived intracardiac pressure-volume catheterization is applicable to mice for an in-depth characterization of right ventricular (RV) function even upon maintained pressure overload. What is the main finding and its importance? Characterization of RV function by the complementary use of echocardiographic imaging together with pressure-volume catheterization reveals ventricular-arterial decoupling upon maintained pressure overload, where RV systolic function correlates with ventricular-arterial coupling rather than contractility, whereas diastolic function correlates well with RV diastolic pressure. This combined approach allows us to phenotype RV function and dysfunction better in genetically modified and/or pharmacologically treated mice. Assessment of right ventricular (RV) function in rodents is a challenge because of the complex RV anatomy and structure. To date, the best characterization of RV function has been achieved by accurate cardiovascular phenotyping, involving a combination of non-invasive imaging and intracardiac pressure-volume measurements. We sought to investigate the feasibility of two complementary phenotyping techniques for the evaluation of RV function in an experimental mouse model of sustained RV pressure overload. Mice underwent either sham surgery (n = 5) or pulmonary artery banding (n = 8) to induce isolated RV pressure overload. After 3 weeks, indices of RV function were assessed by echocardiography (Vevo2100) and closed chest-derived invasive pressure-volume measurements (PVR-1030). Pulmonary artery banding resulted in RV hypertrophy and dilatation accompanied by systolic and diastolic dysfunction. Invasive RV haemodynamic measurements demonstrated an increased end-systolic elastance and arterial elastance after pulmonary artery banding compared with sham operation, resulting in ventricular-arterial decoupling. Regression analysis revealed that tricuspid annular plane systolic excursion is correlated with ventricular-arterial coupling (r² = 0.77, P = 0.002) rather than with RV contractility (r² = -0.61, P = 0.07). Furthermore, the isovolumic relaxation time to ECG-derived R-R interval and the ratio of the early diastolic peak velocity measured by pulsed wave Doppler to the early diastolic peak obtained during tissue Doppler imaging correlate well with RV end-diastolic pressure (r² = 0.87, P = 0.0001 and r² = 0.82, P = 0.0009, respectively). Commonly used indices of systolic RV function are associated with RV-arterial coupling rather than contractility, whereas diastolic indices well correlate with end-diastolic pressure when there is maintained pressure overload.
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Affiliation(s)
- Mario Boehm
- Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardio-Pulmonary System (ECCPS), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Allan Lawrie
- Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany
| | - Jochen Wilhelm
- Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardio-Pulmonary System (ECCPS), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Hossein A Ghofrani
- Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardio-Pulmonary System (ECCPS), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Friedrich Grimminger
- Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardio-Pulmonary System (ECCPS), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Norbert Weissmann
- Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardio-Pulmonary System (ECCPS), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- Pulmonary Vascular Research Group, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Ralph T Schermuly
- Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardio-Pulmonary System (ECCPS), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Baktybek Kojonazarov
- Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardio-Pulmonary System (ECCPS), Member of the German Center for Lung Research (DZL), Giessen, Germany
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13
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Inotropic Effects of Prostacyclins on the Right Ventricle Are Abolished in Isolated Rat Hearts With Right-Ventricular Hypertrophy and Failure. J Cardiovasc Pharmacol 2017; 69:1-12. [PMID: 27652910 DOI: 10.1097/fjc.0000000000000435] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Prostacyclin mimetics are vasodilatory agents used in the treatment of pulmonary arterial hypertension. The direct effects of prostanoids on right-ventricular (RV) function are unknown. We aimed to investigate the direct effects of prostacyclin mimetics on RV function in hearts with and without RV hypertrophy and failure. METHODS Wistar rats were subjected to pulmonary trunk banding to induce compensated RV hypertrophy (n = 32) or manifest RV failure (n = 32). Rats without banding served as healthy controls (n = 30). The hearts were excised and perfused in a Langendorff system and subjected to iloprost, treprostinil, epoprostenol, or MRE-269 in increasing concentrations. The effect on RV function was evaluated using a balloon-tipped catheter inserted into the right ventricle. RESULTS In control hearts, iloprost, treprostinil, and MRE-269 improved RV function. The effect was, however, absent in hearts with RV hypertrophy and failure. Treprostinil and MRE-269 even impaired RV function in hearts with manifest RV failure. CONCLUSIONS Iloprost, treprostinil, and MRE-269 improved RV function in the healthy rat heart. RV hypertrophy abolished the positive inotropic effect, and in the failing right ventricle, MRE-269 and treprostinil impaired RV function. This may be related to changes in prostanoid receptor expression and reduced coronary flow reserve in the hypertrophic and failing right ventricle.
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14
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Bellofiore A, Vanderpool R, Brewis MJ, Peacock AJ, Chesler NC. A novel single-beat approach to assess right ventricular systolic function. J Appl Physiol (1985) 2017; 124:283-290. [PMID: 29025899 DOI: 10.1152/japplphysiol.00258.2017] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Clinical assessment of right ventricular (RV) contractility in diseases such as pulmonary arterial hypertension (PAH) has been hindered by the lack of a robust methodology. Here, a novel, clinically viable, single-beat method was developed to assess end-systolic elastance (Ees), a measure of right ventricular (RV) contractility. We hypothesized that this novel approach reduces uncertainty and interobserver variability in the estimation of the maximum isovolumic pressure (Piso), the key step in single-beat methods. The new method was designed to include a larger portion of the RV pressure data and minimize subjective adjustments by the operator. Data were obtained from right heart catheterization of PAH patients in a multicenter prospective study ( data set 1) and a single-center retrospective study ( data set 2). To obtain Piso, three independent observers used an established single-beat method (based on the first derivative of the pressure waveform) and the novel method (based on the second derivative). Interobserver variability analysis included paired t-test, one-way ANOVA, interclass correlation (ICC) analysis, and a modified Bland-Altman analysis. The Piso values obtained from the two methods were linearly correlated for both data set 1 ( R2 = 0.74) and data set 2 ( R2 = 0.91). Compared with the established method, the novel method resulted in smaller interobserver variability ( P < 0.001), nonsignificant differences between observers, and a narrower confidence interval. By reducing uncertainty and interobserved variability, this novel approach may pave the way for more effective clinical management of PAH. NEW & NOTEWORTHY A novel methodology to assess right ventricular contractility from clinical data is demonstrated. This approach significantly reduces interobserver variability in the analysis of ventricular pressure data, as demonstrated in a relatively large population of subjects with pulmonary hypertension. This study may enable more accurate clinical monitoring of systolic function in subjects with pulmonary hypertension.
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Affiliation(s)
- Alessandro Bellofiore
- Department of Biomedical, Chemical and Materials Engineering, San Jose State University , San Jose, California.,Department of Biomedical Engineering, University of Wisconsin-Madison , Madison, Wisconsin
| | - Rebecca Vanderpool
- Vascular Medicine Institute, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Melanie J Brewis
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital , Glasgow , United Kingdom
| | - Andrew J Peacock
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital , Glasgow , United Kingdom
| | - Naomi C Chesler
- Department of Biomedical Engineering, University of Wisconsin-Madison , Madison, Wisconsin.,Department of Medicine, University of Wisconsin-Madison , Madison, Wisconsin
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15
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Vanderpool RR, Desai AA, Knapp SM, Simon MA, Abidov A, Yuan JXJ, Garcia JGN, Hansen LM, Knoper SR, Naeije R, Rischard FP. How prostacyclin therapy improves right ventricular function in pulmonary arterial hypertension. Eur Respir J 2017; 50:50/2/1700764. [PMID: 28838981 DOI: 10.1183/13993003.00764-2017] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 05/29/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Rebecca R Vanderpool
- Division of Translational and Regenerative Medicine, University of Arizona, Tucson, AZ, USA
| | - Ankit A Desai
- Division of Translational and Regenerative Medicine, University of Arizona, Tucson, AZ, USA.,Division of Cardiology, University of Arizona, Tucson, AZ, USA
| | | | - Marc A Simon
- Vascular Medicine Institute, Heart and Vascular Institute, and Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Aiden Abidov
- Department of Medicine, Wayne State University, and Section of Cardiology, John D. Dingell VA Medical Center, Detroit, MI, USA
| | - Jason X-J Yuan
- Division of Translational and Regenerative Medicine, University of Arizona, Tucson, AZ, USA
| | - Joe G N Garcia
- Division of Translational and Regenerative Medicine, University of Arizona, Tucson, AZ, USA.,Division of Pulmonary, Critical Care, Sleep, and Allergy Medicine, University of Arizona, Tucson, AZ, USA
| | - Lillian M Hansen
- Division of Pulmonary, Critical Care, Sleep, and Allergy Medicine, University of Arizona, Tucson, AZ, USA
| | - Steven R Knoper
- Division of Pulmonary, Critical Care, Sleep, and Allergy Medicine, University of Arizona, Tucson, AZ, USA
| | - Robert Naeije
- Laboratory of Physiology and Pharmacology, Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Franz P Rischard
- Division of Translational and Regenerative Medicine, University of Arizona, Tucson, AZ, USA .,Division of Pulmonary, Critical Care, Sleep, and Allergy Medicine, University of Arizona, Tucson, AZ, USA
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16
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Holmboe S, Andersen A, Jensen RV, Kimose HH, Ilkjær LB, Shen L, Clapp LH, Nielsen-Kudsk JE. Prostacyclins have no direct inotropic effect on isolated atrial strips from the normal and pressure-overloaded human right heart. Pulm Circ 2017; 7:339-347. [PMID: 28597773 PMCID: PMC5467920 DOI: 10.1177/2045893217691532] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Prostacyclins are vasodilatory agents used in the treatment of pulmonary arterial hypertension. The direct effects of prostacyclins on right heart function are still not clarified. The aim of this study was to investigate the possible direct inotropic properties of clinical available prostacyclin mimetics in the normal and the pressure-overloaded human right atrium. Trabeculae from the right atrium were collected during surgery from chronic thromboembolic pulmonary hypertension (CTEPH) patients with pressure-overloaded right hearts, undergoing pulmonary thromboendarterectomy (n = 10) and from patients with normal right hearts operated by valve replacement or coronary bypass surgery (n = 9). The trabeculae were placed in an organ bath, continuously paced at 1 Hz. They were subjected to increasing concentrations of iloprost, treprostinil, epoprostenol, or MRE-269, followed by isoprenaline to elicit a reference inotropic response. The force of contraction was measured continuously. The expression of prostanoid receptors was explored through quantitative polymerase chain reaction (qPCR). Iloprost, treprostinil, epoprostenol, or MRE-269 did not alter force of contraction in any of the trabeculae. Isoprenaline showed a direct inotropic response in both trabeculae from the pressure-overloaded right atrium and from the normal right atrium. Control experiments on ventricular trabeculae from the pig failed to show an inotropic response to the prostacyclin mimetics. qPCR demonstrated varying expression of the different prostanoid receptors in the human atrium. In conclusion, prostacyclin mimetics did not increase the force of contraction of human atrial trabeculae from the normal or the pressure-overloaded right heart. These data suggest that prostacyclin mimetics have no direct inotropic effects in the human right atrium.
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Affiliation(s)
- Sarah Holmboe
- 1 Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Asger Andersen
- 1 Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Rebekka V Jensen
- 1 Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Hans Henrik Kimose
- 2 Department of Thoracic Surgery, Aarhus University Hospital, Aarhus N, Denmark
| | - Lars B Ilkjær
- 2 Department of Thoracic Surgery, Aarhus University Hospital, Aarhus N, Denmark
| | - Lei Shen
- 3 Institute of Cardiovascular Science, University College London, London, UK
| | - Lucie H Clapp
- 3 Institute of Cardiovascular Science, University College London, London, UK
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17
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The Relationship Between the Right Ventricle and its Load in Pulmonary Hypertension. J Am Coll Cardiol 2017; 69:236-243. [DOI: 10.1016/j.jacc.2016.10.047] [Citation(s) in RCA: 381] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 10/03/2016] [Accepted: 10/05/2016] [Indexed: 12/13/2022]
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18
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Myocardial inflammation in experimental acute right ventricular failure: Effects of prostacyclin therapy. J Heart Lung Transplant 2015; 34:1334-45. [DOI: 10.1016/j.healun.2015.05.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 03/27/2015] [Accepted: 05/01/2015] [Indexed: 01/24/2023] Open
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19
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Abstract
Pulmonary arterial hypertension (PAH) is a right heart failure syndrome. In early-stage PAH, the right ventricle tends to remain adapted to afterload with increased contractility and little or no increase in right heart chamber dimensions. However, less than optimal right ventricular (RV)-arterial coupling may already cause a decreased aerobic exercise capacity by limiting maximum cardiac output. In more advanced stages, RV systolic function cannot remain matched to afterload and dilatation of the right heart chamber progressively develops. In addition, diastolic dysfunction occurs due to myocardial fibrosis and sarcomeric stiffening. All these changes lead to limitation of RV flow output, increased right-sided filling pressures and under-filling of the left ventricle, with eventual decrease in systemic blood pressure and altered systolic ventricular interaction. These pathophysiological changes account for exertional dyspnoea and systemic venous congestion typical of PAH. Complete evaluation of RV failure requires echocardiographic or magnetic resonance imaging, and right heart catheterisation measurements. Treatment of RV failure in PAH relies on: decreasing afterload with drugs targeting pulmonary circulation; fluid management to optimise ventricular diastolic interactions; and inotropic interventions to reverse cardiogenic shock. To date, there has been no report of the efficacy of drug treatments that specifically target the right ventricle.
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Affiliation(s)
- Robert Naeije
- Dept of Cardiology, Erasme University Hospital, Brussels, Belgium. Dept of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University Hospital, Bologna, Italy.
| | - Alessandra Manes
- Dept of Cardiology, Erasme University Hospital, Brussels, Belgium. Dept of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University Hospital, Bologna, Italy
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20
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Abstract
Pulmonary arterial hypertension (PAH) includes a heterogeneous group of diseases characterized by pulmonary vasoconstriction and remodeling of the lung circulation. Although PAH is a disease of the lungs, patients with PAH frequently die of right heart failure. Indeed, survival of patients with PAH depends on the adaptive response of the right ventricle (RV) to the changes in the lung circulation. PAH-specific drugs affect the function of the RV through afterload reduction and perhaps also through direct effects on the myocardium. Prostacyclins, type 5 phosphodiesterase inhibitors, and guanylyl cyclase stimulators may directly enhance myocardial contractility through increased cyclic adenosine and guanosine monophosphate availability. Although this may initially improve cardiac performance, the long-term effects on myocardial oxygen consumption and function are unclear. Cardiac effects of endothelin receptor antagonists may be opposite, as endothelin-1 is known to suppress cardiac contractility. Because PAH is increasingly considered as a disease with quasimalignant growth of cells in the pulmonary vascular wall, therapies are being developed that inhibit hypertrophy and angiogenesis, and promote apoptosis. The inherent danger of these therapies is a further compromise to the already ischemic, fibrotic, and dysfunctional RV. More recently, the right heart has been identified as a direct treatment target in PAH. The effects of well established therapies for left heart failure, such as β-adrenergic receptor blockers, inhibitors of the renin-angiotensin system, exercise training, and assist devices, are currently being investigated in PAH. Future treatment of patients with PAH will likely consist of a multifaceted approaches aiming to reduce the pressure in the lung circulation and improving right heart adaptation simultaneously.
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21
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22
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Naeije R, Brimioulle S, Dewachter L. Biomechanics of the right ventricle in health and disease (2013 Grover Conference series). Pulm Circ 2015; 4:395-406. [PMID: 25621153 DOI: 10.1086/677354] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 01/22/2014] [Indexed: 02/02/2023] Open
Abstract
Right ventricular (RV) function is a major determinant of the symptomatology and outcome in pulmonary hypertension. The normal RV is a thin-walled flow generator able to accommodate large changes in venous return but unable to maintain flow output in the presence of a brisk increase in pulmonary artery pressure. The RV chronically exposed to pulmonary hypertension undergoes hypertrophic changes and an increase in contractility, allowing for preserved flow output in response to peripheral demand. Failure of systolic function adaptation (homeometric adaptation, described by Anrep's law of the heart) results in increased dimensions (heterometric adaptation; Starling's law of the heart), with a negative effect on diastolic ventricular interactions, limitation of exercise capacity, and vascular congestion. Ventricular function is described by pressure-volume relationships. The gold standard of systolic function is maximum elastance (E max), or the maximal value of the ratio of pressure to volume. This value is not immediately sensitive to changes in loading conditions. The gold standard of afterload is arterial elastance (E a), defined by the ratio of pressure at E max to stroke volume. The optimal coupling of ventricular function to the arterial circulation occurs at an E max/E a ratio between 1.5 and 2. Patients with severe pulmonary hypertension present with an increased E max, a trend toward decreased E max/E a, and increased RV dimensions, along with progression of the pulmonary vascular disease, systemic factors, and left ventricular function. The molecular mechanisms of RV systolic failure are currently being investigated. It is important to refer biological findings to sound measurements of function. Surrogates for E max and E a are being developed through bedside imaging techniques.
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Affiliation(s)
- Robert Naeije
- Department of Physiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium
| | - Serge Brimioulle
- Department of Physiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium
| | - Laurence Dewachter
- Department of Physiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium
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23
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Zeineh NS, Bachman TN, El-Haddad H, Champion HC. Effects of acute intravenous iloprost on right ventricular hemodynamics in rats with chronic pulmonary hypertension. Pulm Circ 2015; 4:612-8. [PMID: 25610597 DOI: 10.1086/677358] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 02/18/2014] [Indexed: 01/23/2023] Open
Abstract
The inotropic effects of prostacyclins in chronic pulmonary arterial hypertension (PAH) are unclear and may be important in directing patient management in the acute setting. We sought to study the effects of an acute intravenous (IV) infusion of iloprost on right ventricular (RV) contractility in a rat model of chronic PAH. Rats were treated with monocrotaline, 60 mg/kg intraperitoneally, to induce PAH. Six weeks later, baseline hemodynamic assessment was performed with pressure-volume and Doppler flow measurements. In one group of animals, measurements were repeated 10-15 minutes after IV infusion of a fixed dose of iloprost (20 μg/kg). A separate group of rats underwent dose-response assessment. RV contractility and RV-pulmonary artery coupling were assessed by the end-systolic pressure-volume relationship (ESPVR) and end-systolic elastance/effective arterial elastance (Ees/Ea). RV cardiomyocytes were isolated, and intracellular cAMP (cyclic adenosine monophosphate) concentration was measured with a cAMP-specific enzyme immunoassay kit. Animals had evidence of PAH and RV hypertrophy. Right ventricle/(left ventricle + septum) weight was 0.40 ± 0.03. RV systolic pressure (RVSP) was 39.83 ± 1.62 mmHg. Administration of iloprost demonstrated an increase in the slope of the ESPVR from 0.29 ± 0.02 to 0.42 ± 0.05 (P < .05). Ees/Ea increased from 0.63 ± 0.07 to 0.82 ± 0.06 (P < .05). The RV contractility index (max dP/dt normalized for instantaneous pressure) increased from 94.11 to 114.5/s (P < .05), as did the RV ejection fraction, from 48.0% to 52.5% (P < .05). This study suggests a positive inotropic effect of iloprost on a rat model of chronic PAH.
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Affiliation(s)
- Nabil S Zeineh
- Vascular Medicine Institute, Pulmonary Allergy and Critical Care Medicine, Cardiovascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Timothy N Bachman
- Vascular Medicine Institute, Pulmonary Allergy and Critical Care Medicine, Cardiovascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hazim El-Haddad
- Department of Internal Medicine, Wake Forest University Medical Center, Winston-Salem, North Carolina, USA
| | - Hunter C Champion
- Vascular Medicine Institute, Pulmonary Allergy and Critical Care Medicine, Cardiovascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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24
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Matsubara H, Ogawa A. Treatment of idiopathic/hereditary pulmonary arterial hypertension. J Cardiol 2014; 64:243-9. [DOI: 10.1016/j.jjcc.2014.06.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 06/11/2014] [Indexed: 01/09/2023]
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26
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Abstract
The pulmonary circulation is a high-flow and low-pressure circuit. The functional state of the pulmonary circulation is defined by pulmonary vascular pressure-flow relationships conforming to distensible vessel models with a correction for hematocrit. The product of pulmonary arterial compliance and resistance is constant, but with a slight decrease as a result of increased pulsatile hydraulic load in the presence of increased venous pressure or proximal pulmonary arterial obstruction. An increase in left atrial pressure is transmitted upstream with a ratio ≥1 for mean pulmonary artery pressure and ≤1 the diastolic pulmonary pressure. Therefore, the diastolic pressure gradient is more appropriate than the transpulmonary pressure gradient to identify pulmonary vascular disease in left heart conditions. Exercise is associated with a decrease in pulmonary vascular resistance and an increase in pulmonary arterial compliance. Right ventricular function is coupled to the pulmonary circulation with an optimal ratio of end-systolic to arterial elastances of 1.5-2.
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Affiliation(s)
- Robert Naeije
- Department of Physiology, Erasme Campus of the Free University of Brussels, CP 604, 808, Lennik Road, 1070, Brussels, Belgium,
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27
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Holmboe S, Andersen A, Vildbrad MD, Nielsen JM, Ringgaard S, Nielsen-Kudsk JE. Iloprost improves ventricular function in the hypertrophic and functionally impaired right heart by direct stimulation. Pulm Circ 2014; 3:870-9. [PMID: 25006403 DOI: 10.1086/674760] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Accepted: 07/28/2013] [Indexed: 11/03/2022] Open
Abstract
Right heart function is an important predictor of morbidity and mortality in patients suffering from pulmonary arterial hypertension and congenital heart diseases. We investigated whether the prostacyclin analog iloprost has a direct inotropic effect in the pressure-overloaded hypertrophic and dysfunctional right ventricle (RV). Rats were randomized to monocrotaline injection (60 mg/kg; [Formula: see text]), pulmonary trunk banding (PTB; [Formula: see text]), or a sham operation ([Formula: see text]). RV function was evaluated with magnetic resonance imaging, echocardiography, and invasive pressure measurements at baseline, after intravenous administration of placebo, iloprost 10 ng/kg/min, or iloprost 100 ng/kg/min (Ilo100). Infusion of Ilo100 induced a [Formula: see text] ([Formula: see text]) increase in stroke volume in the sham group and a [Formula: see text] ([Formula: see text]) increase in the PTB group. RV [Formula: see text] was elevated by [Formula: see text] ([Formula: see text]) in the sham group and by [Formula: see text] ([Formula: see text]) in the PTB group. An elevation in cardiac output of [Formula: see text] ([Formula: see text]) and an [Formula: see text] ([Formula: see text]) increase in RV systolic pressure were found in the PTB group. Iloprost caused a decrease in mean arterial blood pressure (MAP) in all groups of animals. An equal reduction in MAP induced by the arterial vasodilator nitroprusside did not improve any of the measured parameters of RV function. We conclude that iloprost has inotropic properties directly improving ventricular function in the hypertrophic and dysfunctional right heart of the rat.
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Affiliation(s)
- Sarah Holmboe
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Mads D Vildbrad
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jan M Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Steffen Ringgaard
- Magnetic Resonance Research Centre, Aarhus University Hospital, Aarhus, Denmark
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28
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Bubb KJ, Trinder SL, Baliga RS, Patel J, Clapp LH, MacAllister RJ, Hobbs AJ. Inhibition of phosphodiesterase 2 augments cGMP and cAMP signaling to ameliorate pulmonary hypertension. Circulation 2014; 130:496-507. [PMID: 24899690 DOI: 10.1161/circulationaha.114.009751] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Pulmonary hypertension (PH) is a life-threatening disorder characterized by increased pulmonary artery pressure, remodeling of the pulmonary vasculature, and right ventricular failure. Loss of endothelium-derived nitric oxide (NO) and prostacyclin contributes to PH pathogenesis, and current therapies are targeted to restore these pathways. Phosphodiesterases (PDEs) are a family of enzymes that break down cGMP and cAMP, which underpin the bioactivity of NO and prostacyclin. PDE5 inhibitors (eg, sildenafil) are licensed for PH, but a role for PDE2 in lung physiology and disease has yet to be established. Herein, we investigated whether PDE2 inhibition modulates pulmonary cyclic nucleotide signaling and ameliorates experimental PH. METHODS AND RESULTS The selective PDE2 inhibitor BAY 60-7550 augmented atrial natriuretic peptide- and treprostinil-evoked pulmonary vascular relaxation in isolated arteries from chronically hypoxic rats. BAY 60-7550 prevented the onset of both hypoxia- and bleomycin-induced PH and produced a significantly greater reduction in disease severity when given in combination with a neutral endopeptidase inhibitor (enhances endogenous natriuretic peptides), trepostinil, inorganic nitrate (NO donor), or a PDE5 inhibitor. Proliferation of pulmonary artery smooth muscle cells from patients with pulmonary arterial hypertension was reduced by BAY 60-7550, an effect further enhanced in the presence of atrial natriuretic peptide, NO, and treprostinil. CONCLUSIONS PDE2 inhibition elicits pulmonary dilation, prevents pulmonary vascular remodeling, and reduces the right ventricular hypertrophy characteristic of PH. This favorable pharmacodynamic profile is dependent on natriuretic peptide bioactivity and is additive with prostacyclin analogues, PDE5 inhibitor, and NO. PDE2 inhibition represents a viable, orally active therapy for PH.
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Affiliation(s)
- Kristen J Bubb
- From the William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London (K.J.B., S.L.T., R.S.B., A.J.H.); and Centre for Clinical Pharmacology, University College London (J.P., L.H.C., R.J.M.), London, United Kingdom
| | - Sarah L Trinder
- From the William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London (K.J.B., S.L.T., R.S.B., A.J.H.); and Centre for Clinical Pharmacology, University College London (J.P., L.H.C., R.J.M.), London, United Kingdom
| | - Reshma S Baliga
- From the William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London (K.J.B., S.L.T., R.S.B., A.J.H.); and Centre for Clinical Pharmacology, University College London (J.P., L.H.C., R.J.M.), London, United Kingdom
| | - Jigisha Patel
- From the William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London (K.J.B., S.L.T., R.S.B., A.J.H.); and Centre for Clinical Pharmacology, University College London (J.P., L.H.C., R.J.M.), London, United Kingdom
| | - Lucie H Clapp
- From the William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London (K.J.B., S.L.T., R.S.B., A.J.H.); and Centre for Clinical Pharmacology, University College London (J.P., L.H.C., R.J.M.), London, United Kingdom
| | - Raymond J MacAllister
- From the William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London (K.J.B., S.L.T., R.S.B., A.J.H.); and Centre for Clinical Pharmacology, University College London (J.P., L.H.C., R.J.M.), London, United Kingdom
| | - Adrian J Hobbs
- From the William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London (K.J.B., S.L.T., R.S.B., A.J.H.); and Centre for Clinical Pharmacology, University College London (J.P., L.H.C., R.J.M.), London, United Kingdom.
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Vonk-Noordegraaf A, Haddad F, Chin KM, Forfia PR, Kawut SM, Lumens J, Naeije R, Newman J, Oudiz RJ, Provencher S, Torbicki A, Voelkel NF, Hassoun PM. Right heart adaptation to pulmonary arterial hypertension: physiology and pathobiology. J Am Coll Cardiol 2014; 62:D22-33. [PMID: 24355638 DOI: 10.1016/j.jacc.2013.10.027] [Citation(s) in RCA: 669] [Impact Index Per Article: 66.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 10/22/2013] [Indexed: 12/22/2022]
Abstract
Survival in patients with pulmonary arterial hypertension (PAH) is closely related to right ventricular (RV) function. Although pulmonary load is an important determinant of RV systolic function in PAH, there remains a significant variability in RV adaptation to pulmonary hypertension. In this report, the authors discuss the emerging concepts of right heart pathobiology in PAH. More specifically, the discussion focuses on the following questions. 1) How is right heart failure syndrome best defined? 2) What are the underlying molecular mechanisms of the failing right ventricle in PAH? 3) How are RV contractility and function and their prognostic implications best assessed? 4) What is the role of targeted RV therapy? Throughout the report, the authors highlight differences between right and left heart failure and outline key areas of future investigation.
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Affiliation(s)
| | - François Haddad
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Kelly M Chin
- Department of Internal Medicine, Pulmonary Division, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Paul R Forfia
- Pulmonary Hypertension and Right Heart Failure Program, Temple University Hospital, Philadelphia, Pennsylvania
| | - Steven M Kawut
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joost Lumens
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Robert Naeije
- Department of Pathophysiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium
| | - John Newman
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ronald J Oudiz
- The David Geffen School of Medicine at UCLA, Liu Center for Pulmonary Hypertension, Division of Cardiology, Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Steve Provencher
- Pulmonary Hypertension Research Group, Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Chemin Sainte-Foy, Québec, Canada
| | - Adam Torbicki
- Department of Pulmonary Circulation and Thromboembolic Diseases, Centre of Postgraduate Medical Education, ECZ, Otwock, Poland
| | - Norbert F Voelkel
- Division of Pulmonary and Critical Care Medicine and Victoria Johnson Lab for Lung Research, Virginia Commonwealth University, Richmond, Virginia; Johns Hopkins University, Baltimore, Maryland
| | - Paul M Hassoun
- Department of Internal Medicine, Pulmonary Division, University of Texas Southwestern Medical Center, Dallas, Texas
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Mukherjee B, Howard L. Combination therapy in pulmonary arterial hypertension: do we have the right strategy? Expert Rev Respir Med 2014; 5:191-205. [DOI: 10.1586/ers.11.13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Pulmonary heart disease (PHD) refers to altered structure or function of the right ventricle occurring in association with abnormal respiratory function. Although nearly always associated with some degree of PH, the degree, nature, severity, and causality of PH in relation to the PHD is not necessarily linear and direct. Abnormal gas exchange is a fundamental underpinning of PHD, affecting pulmonary vascular, cardiac, renal, and neurohormonal systems. Direct and indirect effects of chronic respiratory disease can disrupt the right ventricular-pulmonary arterial (RV-PA) interaction and, likewise, factors such as sympathetic nervous system activation, altered blood viscosity, and salt and water retention can function in a feedback loop to further influence RV-PA function. Left heart function may also be affected, especially in those with pre-existing left heart disease. Thus, the physiologic interactions between abnormal respiratory and cardiovascular function are complex, with PHD representing a heterogeneous end organ effect of an integrated multisystem process. In this review, we propose to separate PHD into two distinct entities, “Type I” and “Type II” PHD. Type I PHD is most common, and refers to subjects with chronic respiratory disease (CRD) where the perturbations in respiratory function dominate over more mild cardiac and circulatory disruptions. In contrast, Type II PHD refers to the smaller subset of patients with more severe pulmonary vascular and right heart dysfunction, whom often present in a fashion similar to patients with PAH. Phenotypic differences are not made by PA pressure alone, but instead by differences in the overall physiology and clinical syndrome. Thus, key differences can be seen in symptomatology, physical signs, cardiac imaging, hemodynamics, and the cardiovascular and gas exchange responses to exercise. Such key baseline differences in the overall physiologic phenotype are likely critical to predicting response to PH specific therapy. Recognizing PHD as distinct phenotypes assists in the necessary distinction of these patients, and may also provide a key clinical and pathophysiologic framework for improved patient selection for future studies investigating the role of pulmonary hypertension-specific therapies in PHD.
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Affiliation(s)
- Paul R Forfia
- Heart Failure and Transplant Cardiology, Pulmonary Hypertension Program, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Methods for measuring right ventricular function and hemodynamic coupling with the pulmonary vasculature. Ann Biomed Eng 2013; 41:1384-98. [PMID: 23423705 DOI: 10.1007/s10439-013-0752-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 01/21/2013] [Indexed: 12/11/2022]
Abstract
The right ventricle (RV) is a pulsatile pump, the efficiency of which depends on proper hemodynamic coupling with the compliant pulmonary circulation. The RV and pulmonary circulation exhibit structural and functional differences with the more extensively investigated left ventricle (LV) and systemic circulation. In light of these differences, metrics of LV function and efficiency of coupling to the systemic circulation cannot be used without modification to characterize RV function and efficiency of coupling to the pulmonary circulation. In this article, we review RV physiology and mechanics, established and novel methods for measuring RV function and hemodynamic coupling, and findings from application of these methods to RV function and coupling changes with pulmonary hypertension. We especially focus on non-invasive measurements, as these may represent the future for clinical monitoring of disease progression and the effect of drug therapies.
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Sood N. Managing an acutely ill patient with pulmonary arterial hypertension. Expert Rev Respir Med 2013; 7:77-83. [DOI: 10.1586/ers.12.73] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ruan KH, Mohite A, So SP, Ruan CH. Establishing novel prostacyclin-synthesizing cells with therapeutic potential against heart diseases. Int J Cardiol 2013; 163:163-9. [DOI: 10.1016/j.ijcard.2011.06.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 05/13/2011] [Accepted: 06/03/2011] [Indexed: 11/25/2022]
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Fang JC, DeMarco T, Givertz MM, Borlaug BA, Lewis GD, Rame JE, Gomberg-Maitland M, Murali S, Frantz RP, McGlothlin D, Horn EM, Benza RL. World Health Organization Pulmonary Hypertension Group 2: Pulmonary hypertension due to left heart disease in the adult—a summary statement from the Pulmonary Hypertension Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2012; 31:913-33. [DOI: 10.1016/j.healun.2012.06.002] [Citation(s) in RCA: 179] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 06/10/2012] [Accepted: 06/11/2012] [Indexed: 01/08/2023] Open
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Abstract
Pulmonary hypertension (PH) is a relatively misunderstood disease, partly related to the fact that many perceive PH to be a singular diagnosis. An unintended consequence of this is the misapplication of the role of the Doppler-Echocardiographic (DE) examination, as well as an underappreciation for its ability to help discern PH pathophysiology prior to right heart catheterization. Since DE often serves as the "gatekeeper" to invasive right heart catheterization, misinterpretation of the DE can lead to missed or delayed diagnosis with devastating consequences. Too often, the primary or nearly exclusive focus of the DE examination is placed on the pulmonary artery pressure estimation. Two main issues with this approach are that Doppler pressure estimations can be inaccurate and even when accurate, without integration of additional 2-D and Doppler information, the clinician will often still not appreciate the pathophysiology of the PH nor its clinical significance. This review will focus on the 2-D and Doppler features necessary to assess pulmonary vascular disease (PVD), discern the salient differences between PVD and pulmonary venous hypertension (PVH), and how to integrate these key DE parameters such that PH pathophysiology can be determined noninvasively and early in the patient workup. Overreliance on any single DE metric, and especially PA pressure estimation, detracts from the overall diagnostic potential of the DE examination. Integrating the relative balance of right and left heart findings, along with proper Doppler interpretation provides a wealth of clinical and pathophysiologic insight prior to invasive hemodynamic assessment. The end results are heightened awareness and improved identification of which patients should be referred for further invasive testing, as well the use of the DE information to compliment the findings from invasive testing.
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Affiliation(s)
- Justin D Roberts
- Department of Medicine, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Haddad F, Peterson T, Fuh E, Kudelko KT, de Jesus Perez V, Skhiri M, Vagelos R, Schnittger I, Denault AY, Rosenthal DN, Doyle RL, Zamanian RT. Characteristics and Outcome After Hospitalization for Acute Right Heart Failure in Patients With Pulmonary Arterial Hypertension. Circ Heart Fail 2011; 4:692-9. [DOI: 10.1161/circheartfailure.110.949933] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- François Haddad
- From the Division of Cardiovascular Medicine (F.H., M.S., R.V., I.S.), Department of Medicine (T.P., E.F.), Division of Pulmonary and Critical Care Medicine (K.T.K., V.d.J.P., R.L.D., R.T.Z.), and Division of Cardiology, Department of Pediatrics (D.N.R.), Stanford University, Stanford, CA; and Department of Anesthesia, Montreal University, Montreal, Quebec, Canada (A.Y.D.)
| | - Tyler Peterson
- From the Division of Cardiovascular Medicine (F.H., M.S., R.V., I.S.), Department of Medicine (T.P., E.F.), Division of Pulmonary and Critical Care Medicine (K.T.K., V.d.J.P., R.L.D., R.T.Z.), and Division of Cardiology, Department of Pediatrics (D.N.R.), Stanford University, Stanford, CA; and Department of Anesthesia, Montreal University, Montreal, Quebec, Canada (A.Y.D.)
| | - Eric Fuh
- From the Division of Cardiovascular Medicine (F.H., M.S., R.V., I.S.), Department of Medicine (T.P., E.F.), Division of Pulmonary and Critical Care Medicine (K.T.K., V.d.J.P., R.L.D., R.T.Z.), and Division of Cardiology, Department of Pediatrics (D.N.R.), Stanford University, Stanford, CA; and Department of Anesthesia, Montreal University, Montreal, Quebec, Canada (A.Y.D.)
| | - Kristina T. Kudelko
- From the Division of Cardiovascular Medicine (F.H., M.S., R.V., I.S.), Department of Medicine (T.P., E.F.), Division of Pulmonary and Critical Care Medicine (K.T.K., V.d.J.P., R.L.D., R.T.Z.), and Division of Cardiology, Department of Pediatrics (D.N.R.), Stanford University, Stanford, CA; and Department of Anesthesia, Montreal University, Montreal, Quebec, Canada (A.Y.D.)
| | - Vinicio de Jesus Perez
- From the Division of Cardiovascular Medicine (F.H., M.S., R.V., I.S.), Department of Medicine (T.P., E.F.), Division of Pulmonary and Critical Care Medicine (K.T.K., V.d.J.P., R.L.D., R.T.Z.), and Division of Cardiology, Department of Pediatrics (D.N.R.), Stanford University, Stanford, CA; and Department of Anesthesia, Montreal University, Montreal, Quebec, Canada (A.Y.D.)
| | - Mehdi Skhiri
- From the Division of Cardiovascular Medicine (F.H., M.S., R.V., I.S.), Department of Medicine (T.P., E.F.), Division of Pulmonary and Critical Care Medicine (K.T.K., V.d.J.P., R.L.D., R.T.Z.), and Division of Cardiology, Department of Pediatrics (D.N.R.), Stanford University, Stanford, CA; and Department of Anesthesia, Montreal University, Montreal, Quebec, Canada (A.Y.D.)
| | - Randall Vagelos
- From the Division of Cardiovascular Medicine (F.H., M.S., R.V., I.S.), Department of Medicine (T.P., E.F.), Division of Pulmonary and Critical Care Medicine (K.T.K., V.d.J.P., R.L.D., R.T.Z.), and Division of Cardiology, Department of Pediatrics (D.N.R.), Stanford University, Stanford, CA; and Department of Anesthesia, Montreal University, Montreal, Quebec, Canada (A.Y.D.)
| | - Ingela Schnittger
- From the Division of Cardiovascular Medicine (F.H., M.S., R.V., I.S.), Department of Medicine (T.P., E.F.), Division of Pulmonary and Critical Care Medicine (K.T.K., V.d.J.P., R.L.D., R.T.Z.), and Division of Cardiology, Department of Pediatrics (D.N.R.), Stanford University, Stanford, CA; and Department of Anesthesia, Montreal University, Montreal, Quebec, Canada (A.Y.D.)
| | - Andre Y. Denault
- From the Division of Cardiovascular Medicine (F.H., M.S., R.V., I.S.), Department of Medicine (T.P., E.F.), Division of Pulmonary and Critical Care Medicine (K.T.K., V.d.J.P., R.L.D., R.T.Z.), and Division of Cardiology, Department of Pediatrics (D.N.R.), Stanford University, Stanford, CA; and Department of Anesthesia, Montreal University, Montreal, Quebec, Canada (A.Y.D.)
| | - David N. Rosenthal
- From the Division of Cardiovascular Medicine (F.H., M.S., R.V., I.S.), Department of Medicine (T.P., E.F.), Division of Pulmonary and Critical Care Medicine (K.T.K., V.d.J.P., R.L.D., R.T.Z.), and Division of Cardiology, Department of Pediatrics (D.N.R.), Stanford University, Stanford, CA; and Department of Anesthesia, Montreal University, Montreal, Quebec, Canada (A.Y.D.)
| | - Ramona L. Doyle
- From the Division of Cardiovascular Medicine (F.H., M.S., R.V., I.S.), Department of Medicine (T.P., E.F.), Division of Pulmonary and Critical Care Medicine (K.T.K., V.d.J.P., R.L.D., R.T.Z.), and Division of Cardiology, Department of Pediatrics (D.N.R.), Stanford University, Stanford, CA; and Department of Anesthesia, Montreal University, Montreal, Quebec, Canada (A.Y.D.)
| | - Roham T. Zamanian
- From the Division of Cardiovascular Medicine (F.H., M.S., R.V., I.S.), Department of Medicine (T.P., E.F.), Division of Pulmonary and Critical Care Medicine (K.T.K., V.d.J.P., R.L.D., R.T.Z.), and Division of Cardiology, Department of Pediatrics (D.N.R.), Stanford University, Stanford, CA; and Department of Anesthesia, Montreal University, Montreal, Quebec, Canada (A.Y.D.)
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Wong YY, Ruiter G, Lubberink M, Raijmakers PG, Knaapen P, Marcus JT, Boonstra A, Lammertsma AA, Westerhof N, van der Laarse WJ, Vonk-Noordegraaf A. Right Ventricular Failure in Idiopathic Pulmonary Arterial Hypertension Is Associated With Inefficient Myocardial Oxygen Utilization. Circ Heart Fail 2011; 4:700-6. [DOI: 10.1161/circheartfailure.111.962381] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yeun Ying Wong
- From the Department of Pulmonology (Y.W., G.R., A.B., A.V.-N.), the Department of Physiology (Y.Y.W., G.R., A.B., N.W., W.J.v.d.L), the Department of Nuclear Medicine and PET Research (M.L., P.G.R., A.A.L.), the Department of Cardiology (P.K.), and the Department of Physics and Medical Technology (J.T.M.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Gerrina Ruiter
- From the Department of Pulmonology (Y.W., G.R., A.B., A.V.-N.), the Department of Physiology (Y.Y.W., G.R., A.B., N.W., W.J.v.d.L), the Department of Nuclear Medicine and PET Research (M.L., P.G.R., A.A.L.), the Department of Cardiology (P.K.), and the Department of Physics and Medical Technology (J.T.M.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Mark Lubberink
- From the Department of Pulmonology (Y.W., G.R., A.B., A.V.-N.), the Department of Physiology (Y.Y.W., G.R., A.B., N.W., W.J.v.d.L), the Department of Nuclear Medicine and PET Research (M.L., P.G.R., A.A.L.), the Department of Cardiology (P.K.), and the Department of Physics and Medical Technology (J.T.M.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Pieter G. Raijmakers
- From the Department of Pulmonology (Y.W., G.R., A.B., A.V.-N.), the Department of Physiology (Y.Y.W., G.R., A.B., N.W., W.J.v.d.L), the Department of Nuclear Medicine and PET Research (M.L., P.G.R., A.A.L.), the Department of Cardiology (P.K.), and the Department of Physics and Medical Technology (J.T.M.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Paul Knaapen
- From the Department of Pulmonology (Y.W., G.R., A.B., A.V.-N.), the Department of Physiology (Y.Y.W., G.R., A.B., N.W., W.J.v.d.L), the Department of Nuclear Medicine and PET Research (M.L., P.G.R., A.A.L.), the Department of Cardiology (P.K.), and the Department of Physics and Medical Technology (J.T.M.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - J. Tim Marcus
- From the Department of Pulmonology (Y.W., G.R., A.B., A.V.-N.), the Department of Physiology (Y.Y.W., G.R., A.B., N.W., W.J.v.d.L), the Department of Nuclear Medicine and PET Research (M.L., P.G.R., A.A.L.), the Department of Cardiology (P.K.), and the Department of Physics and Medical Technology (J.T.M.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Anco Boonstra
- From the Department of Pulmonology (Y.W., G.R., A.B., A.V.-N.), the Department of Physiology (Y.Y.W., G.R., A.B., N.W., W.J.v.d.L), the Department of Nuclear Medicine and PET Research (M.L., P.G.R., A.A.L.), the Department of Cardiology (P.K.), and the Department of Physics and Medical Technology (J.T.M.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Adriaan A. Lammertsma
- From the Department of Pulmonology (Y.W., G.R., A.B., A.V.-N.), the Department of Physiology (Y.Y.W., G.R., A.B., N.W., W.J.v.d.L), the Department of Nuclear Medicine and PET Research (M.L., P.G.R., A.A.L.), the Department of Cardiology (P.K.), and the Department of Physics and Medical Technology (J.T.M.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Nico Westerhof
- From the Department of Pulmonology (Y.W., G.R., A.B., A.V.-N.), the Department of Physiology (Y.Y.W., G.R., A.B., N.W., W.J.v.d.L), the Department of Nuclear Medicine and PET Research (M.L., P.G.R., A.A.L.), the Department of Cardiology (P.K.), and the Department of Physics and Medical Technology (J.T.M.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Willem J. van der Laarse
- From the Department of Pulmonology (Y.W., G.R., A.B., A.V.-N.), the Department of Physiology (Y.Y.W., G.R., A.B., N.W., W.J.v.d.L), the Department of Nuclear Medicine and PET Research (M.L., P.G.R., A.A.L.), the Department of Cardiology (P.K.), and the Department of Physics and Medical Technology (J.T.M.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Anton Vonk-Noordegraaf
- From the Department of Pulmonology (Y.W., G.R., A.B., A.V.-N.), the Department of Physiology (Y.Y.W., G.R., A.B., N.W., W.J.v.d.L), the Department of Nuclear Medicine and PET Research (M.L., P.G.R., A.A.L.), the Department of Cardiology (P.K.), and the Department of Physics and Medical Technology (J.T.M.), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
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Pavelescu A, Naeije R. Effects of epoprostenol and sildenafil on right ventricular function in hypoxic volunteers: a tissue Doppler imaging study. Eur J Appl Physiol 2011; 112:1285-94. [DOI: 10.1007/s00421-011-2085-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 07/09/2011] [Indexed: 11/24/2022]
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Simon MA, Pinsky MR. Right ventricular dysfunction and failure in chronic pressure overload. Cardiol Res Pract 2011; 2011:568095. [PMID: 21559218 PMCID: PMC3087982 DOI: 10.4061/2011/568095] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Accepted: 01/25/2011] [Indexed: 11/20/2022] Open
Abstract
Right ventricular (RV) dysfunction is the main cause of death in pulmonary arterial hypertension (PAH). Our understanding of the pathophysiology of RV dysfunction is limited but improving. Methods to better diagnose RV dysfunction earlier and treatments specifically designed to minimize or reverse the remodeling process are likely to improve outcomes. We review the current understanding of RV dysfunction in chronic pressure overload and introduce some novel insights based on recent investigations into pathophysiology, diagnosis, and treatment.
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Affiliation(s)
- Marc A Simon
- Cardiovascular Institute, University of Pittsburgh, Scaife Hall S-554, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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Zoladz JA, Majerczak J, Duda K, Chłopicki S. Endurance training increases exercise-induced prostacyclin release in young, healthy men--relationship with VO2max. Pharmacol Rep 2010; 62:494-502. [PMID: 20631413 DOI: 10.1016/s1734-1140(10)70305-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Revised: 05/31/2010] [Indexed: 01/25/2023]
Abstract
In the present study, we evaluated the effect of 5 weeks of moderate-intensity endurance training on the basal and exercise-induced systemic release of prostacyclin (PGI(2)), as assessed by plasma 6-keto-PGF(1 alpha) concentration. Twelve physically active young men with the following characteristics participated in this study (the mean +/- SD): age, 22.7 +/- 2.0 years; body mass, 76.8 +/- 8.9 kg; BMI, 23.48 +/- 2.17 kg x m(-2); and maximal oxygen uptake (VO(2 max)), 46.1 +/- 4.0 ml x kg(-1) x min(-1). Plasma 6-keto-PGF(1 alpha) concentrations were measured in venous blood samples taken prior to the exercise and at exhaustion (at VO(2 max)) before and after completing the training protocol. On average, the training resulted in a significant increase in VO(2 max) (p = 0.03), power output at VO(2 max) (p = 0.001) and a significant increase (p = 0.05) in the net-exercise-induced increase in plasma 6-keto-PGF(1 alpha) concentration (Delta 6-keto-PGF(1 alpha) i.e., the difference between the end-exercise and pre-exercise 6-keto-PGF(1 alpha) concentrations). No effect of training on the basal PGI(2) concentration was found. Interestingly, within the study sample (n = 12), two subgroups could be defined with a differential pattern of response with respect to Delta 6-keto-PGF(1 alpha) concentrations. In one subgroup (n = 7), a significant increase in Delta 6-keto-PGF(1 alpha) concentration after training was found (p < 0.02) (responders). This enhancement in the exercise-induced PGI(2) release was accompanied by a significant (p < 0.05) increase in VO(2 max) after training. In contrast, in another subgroup (n = 5), there was no observed effect of training on the Delta 6-keto-PGF(1 alpha) concentration and the VO(2 max) after training (non-responders). In both of these subgroups, training did not influence the basal PGI(2) concentration. In conclusion, the endurance training resulted in the adaptive augmentation of the systemic release of PGI(2) in response to exercise, which plays a role in the training-induced increase in VO(2 max) in young, healthy men. The impairment of the training-induced augmentation of PGI(2) release in response to exercise demonstrated in the non-responders subgroup may predispose them to increased cardiovascular risk during vigorous exercise.
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Affiliation(s)
- Jerzy A Zoladz
- Department of Muscle Physiology, Chair of Physiology and Biochemistry, University School of Physical Education, Al. Jana Pawła II 78, PL 31-571 Kraków, Poland.
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Rao S, Bartle D, Patole S. Current and future therapeutic options for persistent pulmonary hypertension in the newborn. Expert Rev Cardiovasc Ther 2010; 8:845-62. [PMID: 20528642 DOI: 10.1586/erc.09.186] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is a potentially life-threatening condition that is characterized by supra-systemic pulmonary vascular resistance causing right-to-left shunting through the ductus arteriosus and/or foramen ovale, leading to a vicious cycle of hypoxemia, acidosis and further pulmonary vasoconstriction. Advances in neonatology including surfactant instillation, high-frequency ventilation, extracorporeal membrane oxygenation and, most importantly, inhaled nitric oxide (INO), have revolutionized the management of PPHN. However, given that INO does not improve oxygenation in a significant proportion (30-40%) of cases, there is an urgent need to consider other therapeutic options for PPHN. The issue is more important for developing nations with a higher PPHN-related health burden and limited resources. This article discusses the evidence about INO in term and preterm neonates in brief, and focuses mainly on the potential alternative drugs in the management of PPHN.
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Affiliation(s)
- Shripada Rao
- Department of Neonatal Paediatrics, KEM Hospital for Women, Bagot road, Subiaco, Perth 6008, Western Australia, Australia
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Activation of apoptotic pathways in experimental acute afterload-induced right ventricular failure. Crit Care Med 2010; 38:1405-13. [PMID: 20431484 DOI: 10.1097/ccm.0b013e3181de8bd3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The pathobiology of persistent right ventricular failure observed after an acute increase in right ventricular afterload remains incompletely understood. We hypothesized that persistent right ventricular dysfunction might be related to activation of apoptotic pathways. DESIGN Prospective, randomized, controlled animal study. SETTING University research laboratory. SUBJECTS Mongrel dogs. INTERVENTIONS Fourteen anesthetized dogs were randomized to a transient 90-min pulmonary artery constriction operation to induce persistent right ventricular failure or to a sham operation followed 30 mins later by hemodynamic measurements and sampling of cardiac tissue. MEASUREMENTS AND MAIN RESULTS We evaluated effective arterial elastance to estimate right ventricular afterload and end-systolic elastance to estimate right ventricular contractility. Transient increase in pulmonary artery pressure persistently increased effective arterial elastance from 0.75 +/- 0.08 to 1.37 +/- 0.18 mm Hg/mL and decreased end-systolic elastance from 1.06 +/- 0.09 to 0.49 +/- 0.09 mm Hg/mL, end-systolic elastance/effective arterial elastance from 1.44 +/- 0.06 to 0.34 +/- 0.03, and cardiac output from 3.78 +/- 0.16 to 1.46 +/- 0.10 L/min, indicating right ventricular failure. At the pathobiologic level, we assessed apoptosis by real-time quantitative polymerase chain reaction, Western blotting, enzyme-linked immunosorbent assay, and immunohistochemistry. As compared with the sham-operated group, and with the left ventricle in animals with persistent right ventricular failure, there were decreased right ventricular and septal expressions of Bcl-2 with no changes in expressions of Bax, resulting in an increased Bax/Bcl-2 ratio. Right ventricular and septal Bcl-XL, and right ventricular Bcl-w gene expressions were decreased as compared with the sham-operated group, whereas Bak gene expression did not change. There were activations of right ventricular caspases-8 and -9 and of right ventricular and septal caspase-3. Diffuse right ventricular and septal apoptosis was confirmed by terminal deoxynucleotidyl transferase dUTP nick-end labeling staining. There were also increased right ventricular and septal protein expressions of tumor necrosis factor-alpha. CONCLUSIONS Acute afterload-induced persistent right ventricular failure appears to be related to an early activation of apoptotic pathways and to a local overexpression of tumor necrosis factor-alpha, a proinflammatory cytokine.
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Jacobs W, Boonstra A, Brand M, Rosenberg DM, Schaaf B, Postmus PE, Vonk Noordegraaf A. Long-term outcomes in pulmonary arterial hypertension in the first-line epoprostenol or first-line bosentan era. J Heart Lung Transplant 2010; 29:1150-8. [PMID: 20580264 DOI: 10.1016/j.healun.2010.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 04/16/2010] [Accepted: 05/06/2010] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The aim of this study was to describe the long-term outcomes in idiopathic pulmonary arterial hypertension (IPAH) treated with first-line bosentan or intravenous (IV) epoprostenol, and additional therapy as needed. METHODS In a single-center, retrospective, longitudinal cohort, data on right heart catheterization, 6-minute walk distance (6MWD), disease progression and mortality were collected. Outcomes were assessed in first-line bosentan and first-line epoprostenol patients. To reduce selection bias due to differences between groups, two independent analyses were performed. First, a comparison was made of World Health Organization (WHO) Functional Class (FC) III patients. Second, to control for disease severity, a matched-pairs analysis was performed, with matching according to baseline cardiac output and exercise capacity and irrespective of FC at baseline. RESULTS Thirty-seven IPAH patients initiated first-line bosentan treatment and 37 first-line IV epoprostenol. Twenty-nine of the bosentan patients and 16 of the IV epoprostenol patients were in WHO FC III; demographic profiles were similar, although hemodynamic measurements and 6MWD suggested more severe disease in the IV epoprostenol group at treatment initiation. At 1 and 3 years, median change in 6MWD for patients initiating bosentan was +54 m (95% confidence interval: -3 to 76) and +71 m (-123 to 116), respectively, and +92 m (17 to 128) and +142 m (-6 to 242) for those on IV epoprostenol. Absence of disease progression of WHO FC III at 1 and 3 years was 72% and 45% with bosentan and 75% and 44% with IV epoprostenol, respectively. Survival at 1 and 3 years was 93% and 89% with bosentan and 94% and 75% with IV epoprostenol, respectively. Results were confirmed in matched-pairs analysis of 16 bosentan and 16 IV epoprostenol patients with similar disease severity. CONCLUSIONS First-line epoprostenol treatment may lead to greater improvement in exercise capacity than first-line bosentan. However, these greater exercise improvements did not translate into longer time to disease progression or survival.
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Affiliation(s)
- Wouter Jacobs
- Department of Pulmonology, VU University Medical Center, Amsterdam, The Netherlands
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Abstract
Acute pulmonary arterial hypertension (PAH), which may complicate the course of many complex disorders, is always underdiagnosed and its treatment frequently begins only after serious complications have developed. Acute PAH is distinctive because they differ in their clinical presentation, diagnostic findings, and response to treatment from chronic PAH. The acute PAH may take either the form of acute onset of chronic PAH or acute PAH or surgery-related PAH. Significant pathophysiologic differences existed between acute and chronic PAH. Therapy of acute PAH should generally be aimed at acutely relieving right ventricular (RV) pressure overload and preventing RV dysfunction. There are three classes of drugs targeting the correction of abnormalities in endothelial dysfunction, which have been approved recently for the treatment of PAH: (1) prostanoids; (2) endothelin receptor antagonists; and (3) phosphodiesterase-5 inhibitors. The efficacy and safety of these compounds have been confirmed in uncontrolled studies in patients with PAH. Intravenous epoprostenol is suggested to serve as the first-line treatment for the most severe patients. In the other situations, the first-line therapy may include bosentan, sildenafil, or a prostacyclin analogue. Recent advances in the management of PAH have markedly improved prognosis.
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Affiliation(s)
- Gan Hui-li
- Cardiac Surgery Department, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Disease, Beijing 100029, China.
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Kooter AJ, Ijzerman RG, Kamp O, Boonstra AB, Smulders YM. No effect of epoprostenol on right ventricular diameter in patients with acute pulmonary embolism: a randomized controlled trial. BMC Pulm Med 2010; 10:18. [PMID: 20353588 PMCID: PMC2859373 DOI: 10.1186/1471-2466-10-18] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 03/30/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Right ventricular dilatation in the setting of acute pulmonary embolism is associated with an adverse prognosis. Treatment with a pulmonary vasodilator has never been studied systematically. We evaluated the effect of epoprostenol on right ventricular diameter and function in patients with acute pulmonary embolism and right ventricular dilatation. METHODS In a randomized, single-blind study, 14 patients with acute pulmonary embolism received epoprostenol or placebo infusion for 24 hours on top of conventional treatment. Effects on right ventricular end-diastolic diameter, systolic pulmonary artery pressure, right ventricle fractional area change and tricuspid annular plane systolic excursion were assessed by serial echocardiography. Furthermore Troponin T and NT-proBNP were measured serially. RESULTS Compared to placebo, epoprostenol was associated with a relative change from baseline in right ventricular end-diastolic diameter of +2% after 2.5 hours and -8% after 24 hours. Epoprostenol did not have a significant effect on systolic pulmonary artery pressure, right ventricular fractional area change and tricuspid annular plane systolic excursion, nor on biochemical parameters. CONCLUSION In patients with acute pulmonary embolism and right ventricular overload, treatment with epoprostenol did not improve right ventricular dilatation or any other measured variables of right ventricular overload. TRIAL REGISTRATION REGISTRATION URL: NCT01014156Medical ethical committee: Medisch-ethische toetsingscommissie (METc) from the VUmc (free university medical centre).
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Affiliation(s)
- Albertus J Kooter
- Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands.
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Badesch DB, Champion HC, Gomez Sanchez MA, Hoeper MM, Loyd JE, Manes A, McGoon M, Naeije R, Olschewski H, Oudiz RJ, Torbicki A. Diagnosis and assessment of pulmonary arterial hypertension. J Am Coll Cardiol 2009; 54:S55-S66. [PMID: 19555859 DOI: 10.1016/j.jacc.2009.04.011] [Citation(s) in RCA: 741] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Accepted: 04/15/2009] [Indexed: 12/23/2022]
Abstract
The diagnosis and assessment of pulmonary arterial hypertension is a rapidly evolving area, with changes occurring in the definition of the disease, screening and diagnostic techniques, and staging and follow-up assessment. The definition of pulmonary hypertension has been simplified, and is now based on currently available evidence. There has been substantial progress in advancing the imaging techniques and biomarkers used to screen patients for the disease and to follow up their response to therapy. The importance of accurate assessment of right ventricular function in following up the clinical course and response to therapy is more fully appreciated. As new therapies are developed for pulmonary arterial hypertension, screening, prompt diagnosis, and accurate assessment of disease severity become increasingly important. A clear definition of pulmonary hypertension and the development of a rational approach to diagnostic assessment and follow-up using both conventional and new tools will be essential to deriving maximal benefit from our expanding therapeutic armamentarium.
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Affiliation(s)
- David B Badesch
- Divisions of Pulmonary Sciences and Critical Care Medicine and Cardiology, University of Colorado Health Sciences Center, Denver, Colorado.
| | - Hunter C Champion
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | | | - Marius M Hoeper
- Department of Respiratory Medicine, University of Hannover Medical School, Hannover, Germany
| | - James E Loyd
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | | | - Robert Naeije
- Departments of Pathophysiology and Cardiology, Erasme Academic Hospital, Free University of Brussels, Brussels, Belgium
| | - Horst Olschewski
- Pulmonology Division, University Clinic of Internal Medicine, Medical University Graz, Graz, Austria
| | - Ronald J Oudiz
- Liu Center for Pulmonary Hypertension, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Adam Torbicki
- Department of Chest Medicine, Institute of Tuberculosis and Lung Diseases, Medical University of Warsaw, Warsaw, Poland
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Prise en charge d’une hypertension pulmonaire en réanimation. Ing Rech Biomed 2009. [DOI: 10.1016/s1959-0318(09)74598-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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