1
|
Egenlauf B, Weinstock KF, Marra AM, Eichstaedt CA, Harutyunova S, Grünig E, Xanthouli P, Benjamin N. Association between right heart size and right ventricular output reserve in patients with pulmonary arterial hypertension. Int J Cardiol 2024:132466. [PMID: 39159755 DOI: 10.1016/j.ijcard.2024.132466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 07/31/2024] [Accepted: 08/16/2024] [Indexed: 08/21/2024]
Abstract
OBJECTIVES Right ventricular (RV) output reserve, defined as increase of cardiac output during exercise, is reduced in patients with pulmonary arterial hypertension (PAH). Aim of this study was to evaluate the association of right heart size measured by echocardiography and invasively measured RV function at rest and during exercise in PAH patients. METHODS Adult PAH-patients who received routine haemodynamic assessment at rest and during exercise by right heart catheterisation and echocardiographic measurement of right heart size (right atrial (RA) and RV area) were included in this study. Clinical, echocardiographic, laboratory, exercise and invasive haemodynamic parameters were retrospectively analysed. The primary endpoint was to assess the association between right heart size and right ventricular function. RESULTS Data from 215 PAH patients (age 58.9 ± 15.9 years, 63.3% female, 62.2% double or triple combination treatment) were analysed in this cross-sectional study. Cardiac index was significantly lower for patients with enlarged RA-area > 18 cm2 at rest, and at 25 and 50 W (all p < 0.001) and for patients with enlarged RV area > 20 cm2 at rest, 25, 50 and 75 W (all p < 0.001). Furthermore, pulmonary vascular resistance and mPAP/CO slope (all p < 0.001) were significantly higher and pulmonary arterial compliance (all p < 0.05) was significantly lower in patients with enlarged RA or RV area. RA and RV area correlated with TAPSE/sPAP (both p < 0.001, R - 0.570 and - 0.530). CONCLUSION This study could underline that an enlargement of RA- and RV-area is associated with an impaired RV function at rest and during exercise in patients with PAH.
Collapse
Affiliation(s)
- B Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg GmbH at Heidelberg University Hospital, Heidelberg, Germany; Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Germany
| | - K F Weinstock
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg GmbH at Heidelberg University Hospital, Heidelberg, Germany; Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - A M Marra
- Department of Translational Medical Sciences, University Federico II of Naples, Via Pansini 5, 80131 Naples, Italy
| | - C A Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg GmbH at Heidelberg University Hospital, Heidelberg, Germany; Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - S Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg GmbH at Heidelberg University Hospital, Heidelberg, Germany; Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Germany
| | - E Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg GmbH at Heidelberg University Hospital, Heidelberg, Germany; Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Germany
| | - P Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg GmbH at Heidelberg University Hospital, Heidelberg, Germany; Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Germany; Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - N Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg GmbH at Heidelberg University Hospital, Heidelberg, Germany; Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Germany.
| |
Collapse
|
2
|
Gopalan D, Riley JYJ, Leong K, Alsanjari S, Auger W, Lindholm P. Computed Tomography Pulmonary Angiography Prediction of Adverse Long-Term Outcomes in Chronic Thromboembolic Pulmonary Hypertension: Correlation with Hemodynamic Measurements Pre- and Post-Pulmonary Endarterectomy. Tomography 2023; 9:1787-1798. [PMID: 37888734 PMCID: PMC10611069 DOI: 10.3390/tomography9050142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/23/2023] [Accepted: 09/24/2023] [Indexed: 10/28/2023] Open
Abstract
CT pulmonary angiography is commonly used in diagnosing chronic thromboembolic pulmonary hypertension (CTEPH). This work was conducted to determine if cardiac chamber size on CTPA may also be useful for predicting the outcome of CTEPH treatment. A retrospective analysis of paired CTPA and right heart hemodynamics in 33 consecutive CTEPH cases before and after pulmonary thromboendarterectomy (PTE) was performed. Semiautomated and manual CT biatrial and biventricular size quantifications were correlated with mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR) and cardiac output. The baseline indexed right atrioventricular volumes were twice the left atrioventricular volumes, with significant (p < 0.001) augmentation of left heart filling following PTE. Except for the left atrial volume to cardiac index, all other chamber ratios significantly correlated with hemodynamics. Left to right ventricular ratio cut point <0.82 has high sensitivity (91% and 97%) and specificity (88% and 85%) for identifying significant elevations of mPAP and PVR, respectively (AUC 0.90 and 0.95), outperforming atrial ratios (sensitivity 78% and 79%, specificity 82% and 92%, and AUC 0.86 and 0.91). Manual LV:RV basal dimension ratio correlates strongly with semiautomated volume ratio (r 0.77, 95% CI 0.64-0.85) and is an expeditious alternative with comparable prognostic utility (AUC 0.90 and 0.95). LV:RV dimension ratio of <1.03 and ≤0.99 (alternatively expressed as RV:LV ratio of >0.97 and ≥1.01) is a simple metric that can be used for CTEPH outcome prediction.
Collapse
Affiliation(s)
- Deepa Gopalan
- Department of Physiology and Pharmacology, Karolinska Institute, 171 77 Stockholm, Sweden;
- Department of Radiology, Imperial College Hospital NHS Trust, London W12 0HS, UK;
| | - Jan Y. J. Riley
- Department of Diagnostic Imaging, Monash Health, Melbourne 3168, Australia;
| | - Kai’en Leong
- Department of Cardiology, Royal Melbourne Hospital, Melbourne 3052, Australia;
| | - Senan Alsanjari
- Department of Radiology, Imperial College Hospital NHS Trust, London W12 0HS, UK;
| | - William Auger
- Department of Pulmonary Medicine, University of California, San Diego, CA 92037, USA;
| | - Peter Lindholm
- Department of Physiology and Pharmacology, Karolinska Institute, 171 77 Stockholm, Sweden;
- Department of Emergency Medicine, University of California, San Diego, CA 92103, USA
| |
Collapse
|
3
|
Benza RL, Langleben D, Hemnes AR, Vonk Noordegraaf A, Rosenkranz S, Thenappan T, Hassoun PM, Preston IR, Ghio S, Badagliacca R, Vizza CD, Lang IM, Meier C, Grünig E. Riociguat and the right ventricle in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2022; 31:31/166/220061. [PMID: 36198418 DOI: 10.1183/16000617.0061-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/22/2022] [Indexed: 11/05/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are progressive diseases that can lead to right heart failure and death. Right ventricular dysfunction, hypertrophy and maladaptive remodelling are consequences of increased right ventricular (RV) afterload in PAH and CTEPH and are indicative of long-term outcomes. Because RV failure is the main cause of morbidity and mortality in PAH and CTEPH, successful treatments should lead to improvements in RV parameters. Riociguat is a soluble guanylate cyclase stimulator approved for the treatment of PAH and inoperable or persistent/recurrent CTEPH after pulmonary endarterectomy. This review examines the current evidence showing the effect of riociguat on the right ventricle, with particular focus on remodelling, function and structural parameters in preclinical models and patients with PAH or CTEPH.
Collapse
Affiliation(s)
- Raymond L Benza
- Dept of Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - David Langleben
- Center for Pulmonary Vascular Disease, Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Dept of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Stephan Rosenkranz
- Dept of Cardiology and Cologne Cardiovascular Research Center, Cologne University Heart Center, Cologne, Germany
| | - Thenappan Thenappan
- Cardiovascular Division, Dept of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Paul M Hassoun
- Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ioana R Preston
- Pulmonary, Critical Care and Sleep Medicine Division, Tufts Medical Center, Boston, MA, USA
| | - Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | | | - Irene M Lang
- Division of Cardiology, Dept of Internal Medicine II, Medical University of Vienna, Allgemeines Krankenhaus, Vienna, Austria
| | | | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik-Heidelberg gGmbH, Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| |
Collapse
|
4
|
Xanthouli P, Miazgowski J, Benjamin N, Gordjani O, Egenlauf B, Harutyunova S, Seeger R, Marra AM, Blank N, Lorenz HM, Grünig E, Eichstaedt CA. Prognostic meaning of right ventricular function and output reserve in patients with systemic sclerosis. Arthritis Res Ther 2022; 24:173. [PMID: 35864554 PMCID: PMC9306074 DOI: 10.1186/s13075-022-02863-1] [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: 03/22/2022] [Accepted: 07/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background The objective of this study was to investigate the prognostic impact of right ventricular (RV) function at rest and during exercise in patients with systemic sclerosis (SSc) presenting for a screening for pulmonary hypertension (PH). Methods In this study, data from SSc patients who underwent routinely performed examinations for PH screening including echocardiography and right heart catheterization at rest and during exercise were analysed. Uni- and multivariable analyses were performed to identify prognostic parameters. Results Out of 280 SSc patients screened for PH, 225 were included in the analysis (81.3% female, mean age 58.1±13.0 years, 68% limited cutaneous SSc, WHO-FC II–III 74%, 24 manifest PH). During the observation period of 3.2±2.7 (median 2.6) years 35 patients died. Tricuspid annular plane systolic excursion (TAPSE) at rest <18 mm (p=0.001), RV output reserve as increase of cardiac index (CI) during exercise <2 l/min (p<0.0001), RV pulmonary vascular reserve (Δ mean pulmonary artery pressure/Δ cardiac output) ≥3 mmHg/l/min (p<0.0001), peak CI <5.5 l/min/m2 (p=0.001), pulmonary arterial compliance <2 ml/mmHg (p=0.002), TAPSE/systolic pulmonary arterial pressure (sPAP) ratio ≤0.6 ml/mmHg (p<0.0001) and echocardiographic qualitative RV function at rest (p<0.0001) significantly predicted worse survival. In the multivariable analysis TAPSE/sPAP ratio and diffusion capacity for carbon monoxide ≤65% were identified as independent prognostic predictors and had 75% sensitivity and 69% specificity to predict future development of pulmonary vascular disease (PVD) during follow-up. Conclusions This study demonstrates that assessment of RV function at rest and during exercise may provide crucial information to identify SSc patients who are at a high risk of poor outcome and for the development of PH and/or PVD.
Collapse
Affiliation(s)
- Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Julia Miazgowski
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Ojan Gordjani
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Rebekka Seeger
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Alberto M Marra
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Translational Medical Sciences, "Federico II" University and School of Medicine, Naples, Italy
| | - Norbert Blank
- Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hanns-Martin Lorenz
- Department of Internal Medicine V: Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany.,Department of Pneumology and Critical Care Medicine, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany
| | - Christina A Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Heidelberg, Germany. .,Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany. .,Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany.
| |
Collapse
|
5
|
Cheng S, Li VWY, Cheung YF. Systolic and diastolic functional reserve of the subpulmonary and systemic right ventricles as assessed by pharmacologic and exercise stress: A systematic review. Echocardiography 2022; 39:310-329. [PMID: 34997638 DOI: 10.1111/echo.15285] [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] [Received: 09/02/2021] [Revised: 11/15/2021] [Accepted: 12/13/2021] [Indexed: 01/11/2023] Open
Abstract
We performed a systematic review of the literature on the assessment of subpulmonary and systemic right ventricular (RV) functional reserve during pharmacological and exercise stress in congenital heart patients and patients with pulmonary arterial hypertension (PAH). Literature search was conducted using PubMed, EMBASE, and MEDLINE from their inception up to August 2020. Of 913 records identified, 56 studies with a total of 1730 patients were included. Of the 56 studies, 23 assessed subpulmonary RV functional reserve in repaired tetralogy of Fallot patients, 19 assessed systemic RV reserve in patients with transposition of the great arteries (TGA) after atrial switch and those with congenitally corrected TGA, and 14 assessed subpulmonary RV research in patients with PAH. Pharmacological and exercise stress was used, respectively, in 22 and 34 studies. The main findings were (1) impairment of RV systolic and diastolic functional reserve, (2) associations between impaired functional reserve and worse baseline functional parameters, and (3) prognostic implications of RV systolic functional reserve on clinical outcomes in patients with volume and/or pressure-loaded subpulmonary and systemic right ventricles. Further studies are required to establish the incremental value of incorporating stress studies of RV systolic and diastolic function in the clinical management algorithm of congenital heart patients and patients with PAH.
Collapse
Affiliation(s)
- Sabine Cheng
- Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Vivian Wing-Yi Li
- Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Yiu-Fai Cheung
- Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, People's Republic of China
| |
Collapse
|
6
|
Sonnweber T, Schneider EM, Nairz M, Theurl I, Weiss G, Tymoszuk P, Löffler-Ragg J. Risk assessment in precapillary pulmonary hypertension: a comparative analysis. Respir Res 2021; 22:28. [PMID: 33478493 PMCID: PMC7818775 DOI: 10.1186/s12931-021-01624-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 01/11/2021] [Indexed: 01/17/2023] Open
Abstract
Background Risk stratification is essential to assess mortality risk and guide treatment in patients with precapillary pulmonary hypertension (PH). We herein compared the accuracy of different currently used PH risk stratification tools and evaluated the significance of particular risk parameters. Methods We conducted a retrospective longitudinal observational cohort study evaluating seven different risk assessment approaches according to the current PH guidelines. A comprehensive assessment including multi-parametric risk stratification was performed at baseline and 4 yearly follow-up time-points. Multi-step Cox hazard analysis was used to analyse and refine risk prediction. Results Various available risk models effectively predicted mortality in patients with precapillary pulmonary hypertension. Right-heart catheter parameters were not essential for risk prediction. Contrary, non-invasive follow-up re-evaluations significantly improved the accuracy of risk estimations. A lack of accuracy of various risk models was found in the intermediate- and high-risk classes. For these patients, an additional evaluation step including assessment of age and right atrium area improved risk prediction significantly. Discussion Currently used abbreviated versions of the ESC/ERS risk assessment tool, as well as the REVEAL 2.0 and REVEAL Lite 2 based risk stratification, lack accuracy to predict mortality in intermediate- and high-risk precapillary pulmonary hypertension patients. An expanded non-invasive evaluation improves mortality risk prediction in these individuals.
Collapse
Affiliation(s)
- Thomas Sonnweber
- Department of Internal Medicine II, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Tyrol, Austria
| | - Eva-Maria Schneider
- Department of Internal Medicine II, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Tyrol, Austria
| | - Manfred Nairz
- Department of Internal Medicine II, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Tyrol, Austria
| | - Igor Theurl
- Department of Internal Medicine II, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Tyrol, Austria
| | - Günter Weiss
- Department of Internal Medicine II, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Tyrol, Austria
| | - Piotr Tymoszuk
- Department of Internal Medicine II, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Tyrol, Austria.
| | - Judith Löffler-Ragg
- Department of Internal Medicine II, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Tyrol, Austria.
| |
Collapse
|
7
|
Grünig E, Eichstaedt CA, Seeger R, Benjamin N. Right Heart Size and Right Ventricular Reserve in Pulmonary Hypertension: Impact on Management and Prognosis. Diagnostics (Basel) 2020; 10:E1110. [PMID: 33371372 PMCID: PMC7767391 DOI: 10.3390/diagnostics10121110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 01/23/2023] Open
Abstract
Various parameters reflecting right heart size, right ventricular function and capacitance have been shown to be prognostically important in patients with pulmonary hypertension (PH). In the advanced disease, patients suffer from right heart failure, which is a main reason for an impaired prognosis. Right heart size has shown to be associated with right ventricular function and reserve and is correlated with prognosis in patients with PH. Right ventricular reserve, defined as the ability of the ventricle to adjust to exercise or pharmacologic stress, is expressed by various parameters, which may be determined invasively by right heart catheterization or by stress-Doppler-echocardiography as a noninvasive approach. As the term "right ventricular contractile reserve" may be misleading, "right ventricular output reserve" seems desirable as a preferred term of increase in cardiac output during exercise. Both right heart size and right ventricular reserve have been shown to be of prognostic importance and may therefore be useful for risk assessment in patients with pulmonary hypertension. In this article we aim to display different aspects of right heart size and right ventricular reserve and their prognostic role in PH.
Collapse
Affiliation(s)
- Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126 Heidelberg, Germany; (C.A.E.); (R.S.); (N.B.)
- Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), 69126 Heidelberg, Germany
| | - Christina A. Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126 Heidelberg, Germany; (C.A.E.); (R.S.); (N.B.)
- Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), 69126 Heidelberg, Germany
- Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120 Heidelberg, Germany
| | - Rebekka Seeger
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126 Heidelberg, Germany; (C.A.E.); (R.S.); (N.B.)
- Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), 69126 Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126 Heidelberg, Germany; (C.A.E.); (R.S.); (N.B.)
- Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), 69126 Heidelberg, Germany
| |
Collapse
|
8
|
Lange TJ, Borst M, Ewert R, Halank M, Klose H, Leuchte H, Meyer FJ, Seyfarth HJ, Skowasch D, Wilkens H, Held M. [Current Aspects of Definition and Diagnosis of Pulmonary Hypertension]. Pneumologie 2020; 74:847-863. [PMID: 32663892 DOI: 10.1055/a-1199-1548] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
At the 6th World Symposium on Pulmonary Hypertension (WSPH), which took place from February 27 until March 1, 2018 in Nice, scientific progress over the past 5 years in the field of pulmonary hypertension (PH) was presented by 13 working groups. The results of the discussion were published as proceedings towards the end of 2018. One of the major changes suggested by the WSPH was the lowering of the diagnostic threshold for PH from ≥ 25 to > 20 mmHg mean pulmonary arterial pressure, measured by right heart catheterization at rest. In addition, the pulmonary vascular resistance was introduced into the definition of PH, which underlines the importance of cardiac output determination at the diagnostic right heart catheterization.In this article, we discuss the rationale and possible consequences of a changed PH definition in the context of the current literature. Further, we provide a current overview on non-invasive and invasive methods for diagnosis, differential diagnosis, and prognosis of PH, including exercise tests.
Collapse
Affiliation(s)
- T J Lange
- Uniklinik Regensburg, Klinik für Innere Medizin II, Bereich Pneumologie, Regensburg
| | - M Borst
- Medizinische Klinik I, Caritas-Krankenhaus, Bad Mergentheim
| | - R Ewert
- Pneumologie, Uniklinik Greifswald, Greifwald
| | - M Halank
- Universitätsklinikum Carl Gustav Carus, Medizinische Klinik 1, Bereich Pneumologie, Dresden
| | - H Klose
- Universitätsklinikum Hamburg-Eppendorf, Abteilung für Pneumologie, Hamburg
| | - H Leuchte
- Klinik der Barmherzigen Schwestern, Krankenhaus Neuwittelsbach, Lehrkrankenhaus der LMU München, München
| | - F J Meyer
- Lungenzentrum München (Bogenhausen-Harlaching), München Klinik gGmbH, München
| | - H-J Seyfarth
- Bereich Pneumologie, Universitätsklinikum Leipzig, Leipzig
| | - D Skowasch
- Universitätsklinikum Bonn, Medizinische Klinik II, Sektion Pneumologie, Bonn
| | - H Wilkens
- Klinik für Innere Medizin V, Universitätsklinikum des Saarlandes, Homburg
| | - M Held
- Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Klinikum Würzburg Mitte, Standort Missioklinik, Würzburg
| |
Collapse
|
9
|
Hołda MK, Szczepanek E, Bielawska J, Palka N, Wojtysiak D, Frączek P, Nowakowski M, Sowińska N, Arent Z, Podolec P, Kopeć G. Changes in heart morphometric parameters over the course of a monocrotaline-induced pulmonary arterial hypertension rat model. J Transl Med 2020; 18:262. [PMID: 32605656 PMCID: PMC7325143 DOI: 10.1186/s12967-020-02440-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 06/25/2020] [Indexed: 12/16/2022] Open
Abstract
Background Aim of this study was to assess changes in cardiac morphometric parameters at different stages of pulmonary arterial hypertension (PAH) using a monocrotaline-induced rat model. Methods Four groups were distinguished: I–control, non-PAH (n = 18); II–early PAH (n = 12); III–end-stage PAH (n = 23); and IV–end-stage PAH with myocarditis (n = 7). Results Performed over the course of PAH in vivo echocardiography showed significant thickening of the right ventricle free wall (end-diastolic dimension), tricuspid annular plane systolic excursion reduction and decrease in pulmonary artery acceleration time normalized to cycle length. No differences in end-diastolic left ventricle free wall thickness measured in echocardiography was observed between groups. Significant increase of right ventricle and decrease of left ventricle systolic pressure was observed over the development of PAH. Thickening and weight increase (241.2% increase) of the right ventricle free wall and significant dilatation of the right ventricle was observed over the course of PAH (p < 0.001). Reduction in the left ventricle free wall thickness was also observed in end-stage PAH (p < 0.001). Significant trend in the left ventricle free wall weight decrease was observed over the course of PAH (p < 0.001, 24.3% reduction). Calculated right/left ventricle free wall weight ratio gradually increased over PAH stages (p < 0.001). The reduction of left ventricle diameter was observed in rats with end-stage PAH both with and without myocarditis (p < 0.001). Conclusions PAH leads to multidimensional changes in morphometric cardiac parameters. Right ventricle morphological and functional failure develop gradually from early stage of PAH, while left ventricle changes develop at the end stages of PAH.
Collapse
Affiliation(s)
- Mateusz K Hołda
- HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Kraków, Poland. .,Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Kraków, Poland. .,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.
| | - Elżbieta Szczepanek
- HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Kraków, Poland
| | | | - Natalia Palka
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Kraków, Poland
| | - Dorota Wojtysiak
- Department of Animal Genetics, Breeding and Ethology, University of Agriculture in Cracow, Kraków, Poland
| | - Paulina Frączek
- Department of Clinical Oncology, University Hospital, Kraków, Poland
| | - Michał Nowakowski
- Center of Experimental and Innovative Medicine, University Center of Veterinary Medicine JU-AU, University of Agriculture in Cracow, Kraków, Poland
| | - Natalia Sowińska
- Center of Experimental and Innovative Medicine, University Center of Veterinary Medicine JU-AU, University of Agriculture in Cracow, Kraków, Poland
| | - Zbigniew Arent
- Center of Experimental and Innovative Medicine, University Center of Veterinary Medicine JU-AU, University of Agriculture in Cracow, Kraków, Poland
| | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Kraków, Poland
| | - Grzegorz Kopeć
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Kraków, Poland
| |
Collapse
|
10
|
Sabbahi A, Severin R, Ozemek C, Phillips SA, Arena R. The role of cardiopulmonary exercise testing and training in patients with pulmonary hypertension: making the case for this assessment and intervention to be considered a standard of care. Expert Rev Respir Med 2020; 14:317-327. [PMID: 31869256 PMCID: PMC7265169 DOI: 10.1080/17476348.2020.1708196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/19/2019] [Indexed: 01/21/2023]
Abstract
Introduction: Pulmonary hypertension (PH) is a broad pathophysiological disorder primarily characterized by increased pulmonary vascular resistance due to multiple possible etiologies. Patients typically present with multiple complaints that worsen as disease severity increases. Although initially discouraged due to safety concerns, exercise interventions for patients with PH have gained wide interest and multiple investigations have established the effective role of exercise training in improving the clinical profile, exercise tolerance, and overall quality of life.Areas covered: In this review, we discuss the pathophysiology of PH during rest and exercise, the role of cardiopulmonary exercise testing (CPX) in the diagnosis and prognosis of PAH, the role of exercise interventions in this patient population, and the expected physiological adaptations to exercise training.Expert opinion: Exercise testing, in particular CPX, provides a wealth of clinically valuable information in the PH population. Moreover, the available evidence strongly supports the safety and efficacy of exercise training as a clinical tool in improving exercise tolerance and quality of life. Although clinical trials investigating the role of exercise in this PH population are relatively few compared to other chronic conditions, current available evidence supports the clinical implementation of exercise training as a safe and effective treatment modality.
Collapse
Affiliation(s)
- Ahmad Sabbahi
- Department of Physical Therapy and the Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
- School of Physical Therapy, South College, Knoxville, TN, USA
- Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Richard Severin
- Department of Physical Therapy and the Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
- Doctor of Physical Therapy Program, Robbins College of Health and Human Sciences, Baylor University, Waco, TX, USA
| | - Cemal Ozemek
- Department of Physical Therapy and the Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Shane A. Phillips
- Department of Physical Therapy and the Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Ross Arena
- Department of Physical Therapy and the Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| |
Collapse
|
11
|
Cladellas M, Garcia-Ribas C, Ble M, Gómez M, Farré N, Mas-Stachurska A, Ivern C, Vila J, Martí-Almor J. Impact of Preoperative Measurement of Right Heart Chambers in the Evaluation of Pulmonary Hypertension Following Aortic Valve Replacement. Chest 2020; 157:1597-1605. [PMID: 31958443 DOI: 10.1016/j.chest.2019.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 11/15/2019] [Accepted: 12/04/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Severe pulmonary hypertension (PH) in patients with aortic stenosis is related to poor prognosis following aortic valve replacement (AVR). Current European PH guidelines recommend adding two different echocardiographic signs to tricuspid regurgitation velocity (TRV) in PH estimation, classifying its probability as low (TRV ≤ 2.8 m/s), intermediate (TRV 2.9-3.4 m/s), and high (TRV > 3.4 m/s). The right ventricle is an important determinant of prognosis in PH. The goal of this study was to analyze the value of right atrial area > 18 cm2 and right ventricular/left ventricular ratio > 1 in the long-term prognosis following AVR, mainly in the intermediate probability group. METHODS This study included 429 consecutive patients (mean age, 73 ± 8 years; 55% male) with a median follow-up of 4.25 years (completed in 98%). Patients were divided into low (n = 247), intermediate (n = 117), and high probability groups (n = 65). The intermediate probability group was divided into two subgroups: subgroup 2a (n = 27; TRV nonmeasurable or ≤ 2.8 m/s and two signs present) and subgroup 2b (n = 90; TRV 2.9-3.4 m/s, and none or only one sign present). RESULTS Overall mortality rates during follow-up of the low, intermediate, and high probability groups were 24%, 32%, and 42%, respectively. High PH probability was an independent predictor of all-cause mortality (hazard ratio [HR], 1.82; 95% CI, 1.11-3.00), but the intermediate probability group did not reach significance following multivariate analysis (HR, 1.40; 95% CI, 0.91-2.16). When the intermediate probability group was divided into subgroups, the subgroup 2a mortality rate (56%) was higher than that of both subgroup 2b (24%; P = .002) and the low probability group (24%; P < .001). Following multivariate analysis, subgroup 2a showed a significantly higher mortality (HR, 2.13; 95% CI, 1.11-4.10) in contrast to subgroup 2b (HR, 1.24; 95% CI, 0.75-2.05), both compared with the low probability group. CONCLUSIONS Incorporating measurement of the right cavities into the PH probability model in the assessment of long-term prognosis following AVR allowed better risk discrimination, especially in the intermediate probability group.
Collapse
Affiliation(s)
- Mercè Cladellas
- Department of Cardiology, Hospital del Mar. Barcelona, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Department of Medicine, Universitat Autónoma de Barcelona.
| | - Cora Garcia-Ribas
- Department of Cardiology, Hospital del Mar. Barcelona, Spain; Department of Medicine, Universitat Autónoma de Barcelona
| | - Mirea Ble
- Department of Cardiology, Hospital del Mar. Barcelona, Spain
| | - Miquel Gómez
- Department of Cardiology, Hospital del Mar. Barcelona, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Department of Medicine, Universitat Autónoma de Barcelona
| | - Núria Farré
- Department of Cardiology, Hospital del Mar. Barcelona, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Department of Medicine, Universitat Autónoma de Barcelona
| | | | - Consol Ivern
- Department of Cardiology, Hospital del Mar. Barcelona, Spain
| | - Joan Vila
- IMIM Hospital del Mar Medical Research Institute, Inflammatory and Cardiovascular Disorders, Barcelona; CIBER Epidemiology and Public Health
| | - Julio Martí-Almor
- Department of Cardiology, Hospital del Mar. Barcelona, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Department of Medicine, Universitat Autónoma de Barcelona
| |
Collapse
|