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Bousseau S, Sobrano Fais R, Gu S, Frump A, Lahm T. Pathophysiology and new advances in pulmonary hypertension. BMJ MEDICINE 2023; 2:e000137. [PMID: 37051026 PMCID: PMC10083754 DOI: 10.1136/bmjmed-2022-000137] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/02/2023] [Indexed: 04/14/2023]
Abstract
Pulmonary hypertension is a progressive and often fatal cardiopulmonary condition characterised by increased pulmonary arterial pressure, structural changes in the pulmonary circulation, and the formation of vaso-occlusive lesions. These changes lead to increased right ventricular afterload, which often progresses to maladaptive right ventricular remodelling and eventually death. Pulmonary arterial hypertension represents one of the most severe and best studied types of pulmonary hypertension and is consistently targeted by drug treatments. The underlying molecular pathogenesis of pulmonary hypertension is a complex and multifactorial process, but can be characterised by several hallmarks: inflammation, impaired angiogenesis, metabolic alterations, genetic or epigenetic abnormalities, influence of sex and sex hormones, and abnormalities in the right ventricle. Current treatments for pulmonary arterial hypertension and some other types of pulmonary hypertension target pathways involved in the control of pulmonary vascular tone and proliferation; however, these treatments have limited efficacy on patient outcomes. This review describes key features of pulmonary hypertension, discusses current and emerging therapeutic interventions, and points to future directions for research and patient care. Because most progress in the specialty has been made in pulmonary arterial hypertension, this review focuses on this type of pulmonary hypertension. The review highlights key pathophysiological concepts and emerging therapeutic directions, targeting inflammation, cellular metabolism, genetics and epigenetics, sex hormone signalling, bone morphogenetic protein signalling, and inhibition of tyrosine kinase receptors.
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Affiliation(s)
- Simon Bousseau
- Division of Pulmonary, Sleep, and Critical Care Medicine, National Jewish Health, Denver, CO, USA
| | - Rafael Sobrano Fais
- Division of Pulmonary, Sleep, and Critical Care Medicine, National Jewish Health, Denver, CO, USA
| | - Sue Gu
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Cardiovascular Pulmonary Research Lab, University of Colorado School of Medicine, Aurora, CO, USA
| | - Andrea Frump
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tim Lahm
- Division of Pulmonary, Sleep, and Critical Care Medicine, National Jewish Health, Denver, CO, USA
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Regional Veteran Affairs Medical Center, Aurora, CO, USA
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Cajigas HR, Kaptzan T, Lewis B, El-Sabbagh A, Al-Hijji M, Eleid M, Alkhouli M, Wang DD, Eng M, Kodali S, George I, Chakravarty T, Pershad A, O'Hair D, Jones N, Makkar R, Reisman M, Leon M, O'Neill W, Rihal C, Guerrero M. The impact of pulmonary hypertension on outcomes of transcatheter mitral valve replacement in mitral annular calcification. Catheter Cardiovasc Interv 2022; 99:1647-1658. [PMID: 35019204 DOI: 10.1002/ccd.30057] [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: 10/04/2021] [Revised: 11/12/2021] [Accepted: 12/14/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To assess the impact of pulmonary hypertension (PH) on outcomes of patients with severe mitral annular calcification (MAC) undergoing transcatheter mitral valve replacement (TMVR). BACKGROUND PH is associated with poor outcomes after mitral valve surgery. Whether the presence of PH in patients with MAC undergoing (TMVR) is associated with poor outcomes, is unknown. METHODS Retrospective evaluation of 116 patients from 51 centers in 11 countries who underwent TMVR with valve in mitral annular calcification (ViMAC) using balloon-expandable aortic transcatheter valves (THVs) from September 2012 to March 2017. Pulmonary artery systolic blood pressure (PASP) by echocardiogram was available in 90 patients. The subjects were stratified based on PASP: No PH = PASP ≤35 mmHg (n = 11); mild to moderate PH = PASP 36-49 mmHg (n = 21) and severe PH = PASP ≥50 mmHg (n = 58). Clinical, procedural, and echocardiographic outcomes were assessed. RESULTS Mean age was 72.7 (±12.8) years, 59 (65.6%) were female, Society of Thoracic Surgeons score was 15.8 + 11.8% and 90.0% where in New York Heart Association (NYHA) class III-IV. There was no significant difference in all-cause mortality at 30 days (no PH = 27.3%, mild-moderate PH = 19.0%, severe PH = 31.6%; p = 0.55) or at 1 year (no PH = 54.5%, mild-moderate PH = 38.1%, severe PH = 56.1%; p = 0.36). No difference in adverse events, NYHA class or amount of residual mitral regurgitation at 1 year were observed between the groups. CONCLUSION This study suggests that the presence of PH in patients with predominantly mitral stenosis with MAC undergoing TMVR does not impact mortality or adverse events. Further studies are needed to fully understand the effect of PH in this group of patients.
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Affiliation(s)
- Hector R Cajigas
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota, USA
| | - Tatiana Kaptzan
- Cardiovascular Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Bradley Lewis
- Division of Biostatistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Abdallah El-Sabbagh
- Department of Cardiovascular Diseases, Mayo Clinic, Jacksonville, Florida, USA
| | - Mohammed Al-Hijji
- Division of Cardiovascular Diseases, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mackram Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Dee Dee Wang
- Division of Cardiovascular Medicine, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, Michigan, USA
| | - Marvin Eng
- Division of Cardiovascular Medicine, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, Michigan, USA
| | - Susheel Kodali
- Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Isaac George
- Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - Tarun Chakravarty
- Division of Cardiology, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Ashish Pershad
- Division of Cardiology, Chandler Regional and Mercy Gilbert Medical Center, Gilbert, Arizona, USA
| | - Daniel O'Hair
- Division of Cardiac Surgery, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, USA
| | - Noah Jones
- Division of Cardiology, Mount Carmel East Hospital, Columbus, Ohio, USA
| | - Raj Makkar
- Division of Cardiovascular Medicine, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, Michigan, USA
| | - Mark Reisman
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Martin Leon
- Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - William O'Neill
- Division of Cardiovascular Diseases, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Charanjit Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Huang ST, Xu N, Sun KP, Chen Q, Cao H. Effect of Treprostinil on the Early Postoperative Prognosis of Patients with Severe Left Heart Valvular Disease Combined with Severe Pulmonary Hypertension. Ann Thorac Cardiovasc Surg 2021; 27:18-24. [PMID: 32493870 PMCID: PMC8043024 DOI: 10.5761/atcs.oa.20-00003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To investigate the effect of treprostinil on the early postoperative prognosis of patients with severe left heart valvular disease combined with severe pulmonary hypertension (PAH). METHODS A retrospective study including 55 patients with severe left heart valvular disease combined with severe PAH who underwent left heart valve replacement in our hospital between January 2019 and May 2019 was conducted. Patients were divided into two groups (treprostinil group and control group), and the clinical data of patients in the two groups were compared and analyzed. RESULTS Compared with the preoperative status, the mean postoperative pulmonary artery pressure (mPAP) in both groups was significantly lower. Compared with the control group, the treprostinil group had a significantly lower mPAP. Moreover, the postoperative mechanical ventilation time, intensive care unit (ICU) stay, and hospital stay of the treprostinil group were significantly shorter than those of the control group. There were no serious drug-related side effects in either group. CONCLUSIONS Treprostinil can improve the early postoperative prognosis of patients with severe left heart valvular disease combined with severe PAH undergoing prosthetic valve replacement.
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Affiliation(s)
- Shu-Ting Huang
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Ning Xu
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Kai-Peng Sun
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Qiang Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
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Borde DP, Asegaonkar B, Khade S, Puranik M, George A, Joshi S. Impact of preoperative pulmonary arterial hypertension on early and late outcomes in patients undergoing valve surgery for rheumatic heart disease. Indian J Anaesth 2019; 62:963-971. [PMID: 30636798 PMCID: PMC6299764 DOI: 10.4103/ija.ija_374_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background and Aims There is conflicting evidence on adverse effect of Pulmonary Arterial Hypertension (PAH) on outcomes after cardiac surgery for rheumatic heart disease (RHD). The authors studied Indian patients with RHD and preoperative PAH, who undergo cardiac surgery with a hypothesis that they have poor short and long-term outcomes. Methods This was a retrospective observational study of 407 patients. The patients were divided in three groups based on PAH estimated on echocardiograph as; no or mild PAH (pulmonary artery systolic pressure (PASP) <30 mm of Hg); moderate PAH (PASP 31-55 mm of Hg) and severe PAH (PASP >55 mm of Hg). The primary endpoint was in-hospital mortality and major morbidities; while secondary endpoint was long-term survival. Results In-hospital mortality was 24 (5.9%); and was not different in patients with severe, (9.1%), moderate (4.5%) or mild PAH (2.8%) (P = 0.09). Patients with severe PAH had higher incidence of prolonged ventilation (P = 0.007). Factors independently associated with mortality were; >2-packed cell transfusion, prolonged ventilation and acute kidney injury but not moderate and severe PAH. Patients with mitral stenosis (MS) and severe PAH had significantly higher mortality as compared to no or mild PAH (P = 0.03) on long-term follow-up [81.37% (mean duration 19.40 ± 14.10 months)], mortality was 8% and not statistically different (P = 0.25) across PAH categories. Conclusion Moderate and severe PAH does not affect short and long term outcomes of patients undergoing valve surgery for RHD. Patients with MS with severe PAH had higher mortality compared to those with no PAH.
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Affiliation(s)
- Deepak Prakash Borde
- Department of Cardiac Anesthesia, Ozone Anesthesia Group, Aurangabad, Maharashtra, India
| | - Balaji Asegaonkar
- Department of Cardiac Anesthesia, Ozone Anesthesia Group, Aurangabad, Maharashtra, India
| | - Sujit Khade
- Department of Cardiac Anesthesia, Ozone Anesthesia Group, Aurangabad, Maharashtra, India
| | - Manish Puranik
- Department of Cardiac Surgery, Seth Nandlal Dhoot Hospital, Aurangabad, Maharashtra, India
| | - Antony George
- Department of Cardiac Anesthesia, Lissie Hospital, Kochi, Kerala, India
| | - Shreedhar Joshi
- Department of Cardiac Anesthesia, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka, India
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