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Goliopoulou A, Oikonomou E, Theofilis P, Tsigkou V, Makavos G, Kourampi I, Katsioupa M, Antoniou VD, Ikonomidis I, Lambadiari V, Tsatsaragkou A, Sarantos S, Zakynthinos GE, Vavuranakis M, Siasos G. Impairment in Right Ventricular-Pulmonary Arterial Coupling in Overweight and Obesity. J Clin Med 2024; 13:3389. [PMID: 38929919 PMCID: PMC11203835 DOI: 10.3390/jcm13123389] [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: 04/18/2024] [Revised: 05/28/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
Background: The association of obesity with right ventricular function and the interplay between right heart and pulmonary circulation is incompletely understood. We evaluate the role of obesity as a determinant of right ventricular-pulmonary artery coupling (RVAC). Methods: We retrospectively studied consecutive subjects without overt cardiovascular or pulmonary disease. Subjects were stratified according to body mass index (BMI) as normal weight, overweight, or obese. A transthoracic echocardiographic study was used to assess left and right heart functional and structural parameters. RVAC was assessed using the ratio of peak systolic velocity of the tricuspid annulus to pulmonary artery systolic pressure (PASP). Results: A total of 145 subjects were enrolled with diabetes mellitus incidence higher in obese. There was no difference in left ventricular global longitudinal strain and in PASP or markers of right ventricular systolic function based on BMI. RVAC was significantly lower in the presence of obesity (normal weight: 0.52 (0.19) cm·(sec·mmHg)-1 vs. overweight: 0.47 (0.16) cm·(sec·mmHg)-1 vs. obese: 0.43 (0.14) cm·(sec·mmHg)-1, p = 0.03), even after adjustment for confounders (β: -0.085, 95% confidence interval: -0.163, -0.009, p = 0.029). Conclusions: Our findings highlight the relationship between metabolic impairment and RVAC, suggesting additional mechanisms for heart failure development observed in obese subjects.
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Affiliation(s)
- Athina Goliopoulou
- Third Department of Cardiology, Thoracic Diseases General Hospital Sotiria, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.G.); (V.T.); (G.M.); (M.K.); (V.-D.A.); (A.T.); (S.S.); (G.E.Z.); (M.V.); (G.S.)
| | - Evangelos Oikonomou
- Third Department of Cardiology, Thoracic Diseases General Hospital Sotiria, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.G.); (V.T.); (G.M.); (M.K.); (V.-D.A.); (A.T.); (S.S.); (G.E.Z.); (M.V.); (G.S.)
| | - Panagiotis Theofilis
- First Department of Cardiology, Hippokration General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Vasiliki Tsigkou
- Third Department of Cardiology, Thoracic Diseases General Hospital Sotiria, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.G.); (V.T.); (G.M.); (M.K.); (V.-D.A.); (A.T.); (S.S.); (G.E.Z.); (M.V.); (G.S.)
| | - George Makavos
- Third Department of Cardiology, Thoracic Diseases General Hospital Sotiria, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.G.); (V.T.); (G.M.); (M.K.); (V.-D.A.); (A.T.); (S.S.); (G.E.Z.); (M.V.); (G.S.)
| | - Islam Kourampi
- Third Department of Cardiology, Thoracic Diseases General Hospital Sotiria, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.G.); (V.T.); (G.M.); (M.K.); (V.-D.A.); (A.T.); (S.S.); (G.E.Z.); (M.V.); (G.S.)
| | - Maria Katsioupa
- Third Department of Cardiology, Thoracic Diseases General Hospital Sotiria, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.G.); (V.T.); (G.M.); (M.K.); (V.-D.A.); (A.T.); (S.S.); (G.E.Z.); (M.V.); (G.S.)
| | - Vaios-Dionysios Antoniou
- Third Department of Cardiology, Thoracic Diseases General Hospital Sotiria, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.G.); (V.T.); (G.M.); (M.K.); (V.-D.A.); (A.T.); (S.S.); (G.E.Z.); (M.V.); (G.S.)
| | - Ignatios Ikonomidis
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (I.I.); (V.L.)
| | - Vaia Lambadiari
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (I.I.); (V.L.)
| | - Aikaterini Tsatsaragkou
- Third Department of Cardiology, Thoracic Diseases General Hospital Sotiria, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.G.); (V.T.); (G.M.); (M.K.); (V.-D.A.); (A.T.); (S.S.); (G.E.Z.); (M.V.); (G.S.)
| | - Savvas Sarantos
- Third Department of Cardiology, Thoracic Diseases General Hospital Sotiria, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.G.); (V.T.); (G.M.); (M.K.); (V.-D.A.); (A.T.); (S.S.); (G.E.Z.); (M.V.); (G.S.)
| | - George E. Zakynthinos
- Third Department of Cardiology, Thoracic Diseases General Hospital Sotiria, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.G.); (V.T.); (G.M.); (M.K.); (V.-D.A.); (A.T.); (S.S.); (G.E.Z.); (M.V.); (G.S.)
| | - Manolis Vavuranakis
- Third Department of Cardiology, Thoracic Diseases General Hospital Sotiria, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.G.); (V.T.); (G.M.); (M.K.); (V.-D.A.); (A.T.); (S.S.); (G.E.Z.); (M.V.); (G.S.)
| | - Gerasimos Siasos
- Third Department of Cardiology, Thoracic Diseases General Hospital Sotiria, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (A.G.); (V.T.); (G.M.); (M.K.); (V.-D.A.); (A.T.); (S.S.); (G.E.Z.); (M.V.); (G.S.)
- Cardiovascular Division, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA 02115, USA
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Topyła-Putowska W, Tomaszewski M, Wojtkowska A, Wysokiński A. Novel Echocardiographic Measurements of Right Ventricular-Pulmonary Artery Coupling in Predicting the Prognosis of Precapillary Pulmonary Hypertension. J Pers Med 2023; 13:1627. [PMID: 38138854 PMCID: PMC10744346 DOI: 10.3390/jpm13121627] [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: 10/22/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Currently, there are many parameters with proven prognostic significance in pulmonary hypertension (PH). Recently, the parameters defining right ventricular-pulmonary artery coupling (RVPAC) have gained clinical importance. In our study, we investigated the prognostic potential of previously known single echocardiographic parameters and new parameters reflecting RVPAC in patients with precapillary PH. OBJECTIVE Our study aimed to evaluate the prognostic value of selected echocardiographic parameters and the neutrophil-lymphocyte ratio (NLR) in adults with precapillary PH. METHODS This study included 39 patients (74% women; average age, 63 years) with precapillary PH: pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH). The mean follow-up period was 16.6 ± 13.3 months. Twelve patients (31%) died during the observation time. We measured several echocardiographic parameters, which reflect right ventricular function, pulmonary hemodynamics, and RVPAC. To assess disease progression and the patient's functional capacity, the World Health Organization functional class (WHO FC) was determined. The patient's physical capacity was also evaluated using the 6 min walk test (6MWT). The analysis included values of the N-terminal prohormone brain natriuretic peptide (NT-proBNP) and NLR. RESULTS TAPSE × AcT and TAPSE/sPAP were shown to statistically and significantly correlate with PH predictors, including WHO-FC, 6MWT, and NT-proBNP. Univariate Cox proportional hazards regression analysis revealed that AcT, TAPSE, mPAP, TAPSE/sPAP, RAP, TRPG/AcT, TAPSE × AcT, and NLRs are good predictors of mortality in patients with PH. In addition, the ROC curve analysis showed that TAPSE × AcT is a better predictor of PH-related deaths than TAPSE/sPAP and TAPSE alone. In our study, patients with TAPSE × AcT values < 126.36 had shorter survival times (sensitivity = 72.7%; specificity = 80.0%). CONCLUSIONS TAPSE × AcT is a novel, promising, and practicable echocardiographic parameter reflecting RVPAC, which is comparable to TAPSE/sPAP. Moreover, TAPSE × AcT can be a useful parameter in assessing the severity and prognosis of patients with precapillary PH.
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Affiliation(s)
- Weronika Topyła-Putowska
- Department of Cardiology, Medical University of Lublin, 20-059 Lublin, Poland; (M.T.); (A.W.); (A.W.)
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Kirk ME, Merit VT, Moeslund N, Dragsbaek SJ, Hansen JV, Andersen A, Lyhne MD. Impact of sternotomy and pericardiotomy on cardiopulmonary haemodynamics in a large animal model. Exp Physiol 2023; 108:762-771. [PMID: 36892095 PMCID: PMC10988510 DOI: 10.1113/ep090919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/14/2023] [Indexed: 03/10/2023]
Abstract
NEW FINDINGS What is the central question of this study? Invasive cardiovascular instrumentation can occur through closed- or open-chest approaches. To what extent will sternotomy and pericardiotomy affect cardiopulmonary variables? What is the main finding and its importance? Opening of the thorax decreased mean systemic and pulmonary pressures. Left ventricular function improved, but no changes were observed in right ventricular systolic measures. No consensus or recommendation exists regarding instrumentation. Methodological differences risk compromising rigour and reproducibility in preclinical research. ABSTRACT Animal models of cardiovascular disease are often evaluated by invasive instrumentation for phenotyping. As no consensus exists, both open- and closed-chest approaches are used, which might compromise rigour and reproducibility in preclinical research. We aimed to quantify the cardiopulmonary changes induced by sternotomy and pericardiotomy in a large animal model. Seven pigs were anaesthetized, mechanically ventilated and evaluated by right heart catheterization and bi-ventricular pressure-volume loop recordings at baseline and after sternotomy and pericardiotomy. Data were compared by ANOVA or the Friedmann test where appropriate, with post-hoc analyses to control for multiple comparisons. Sternotomy and pericardiotomy caused reductions in mean systemic (-12 ± 11 mmHg, P = 0.027) and pulmonary pressures (-4 ± 3 mmHg, P = 0.006) and airway pressures. Cardiac output decreased non-significantly (-1329 ± 1762 ml/min, P = 0.052). Left ventricular afterload decreased, with an increase in ejection fraction (+9 ± 7%, P = 0.027) and coupling. No changes were observed in right ventricular systolic function or arterial blood gases. In conclusion, open- versus closed-chest approaches to invasive cardiovascular phenotyping cause a systematic difference in key haemodynamic variables. Researchers should adopt the most appropriate approach to ensure rigour and reproducibility in preclinical cardiovascular research.
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Affiliation(s)
- Mathilde Emilie Kirk
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
- Department of CardiologyAarhus University HospitalAarhusDenmark
| | - Victor Tang Merit
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
- Department of CardiologyAarhus University HospitalAarhusDenmark
| | - Niels Moeslund
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
- Department of Cardiac, Lung and Vascular SurgeryAarhus University HospitalAarhusDenmark
| | - Simone Juel Dragsbaek
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
- Department of CardiologyAarhus University HospitalAarhusDenmark
| | - Jacob Valentin Hansen
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
- Department of CardiologyAarhus University HospitalAarhusDenmark
| | - Asger Andersen
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
- Department of CardiologyAarhus University HospitalAarhusDenmark
| | - Mads Dam Lyhne
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
- Department of Anaesthesiology and Intensive CareAarhus University HospitalAarhusDenmark
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4
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Forfia P, Benza R, D'Alto M, De Marco T, Elwing JM, Frantz R, Haddad F, Oudiz R, Preston IR, Rosenkranz S, Ryan J, Schilz R, Shlobin OA, Vachiery J, Vizza CD, Vonk Noordegraaf A, Sketch MR, Broderick M, McLaughlin V. The heart of the matter: Right heart imaging indicators for treatment escalation in pulmonary arterial hypertension. Pulm Circ 2023; 13:e12240. [PMID: 37222992 PMCID: PMC10201108 DOI: 10.1002/pul2.12240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/27/2023] [Accepted: 05/03/2023] [Indexed: 05/25/2023] Open
Abstract
Right heart (RH) structure and function are major determinants of symptoms and prognosis in pulmonary arterial hypertension (PAH). RH imaging provides detailed information, but evidence and guidelines on the use of RH imaging in treatment decisions are limited. We conducted a Delphi study to gather expert opinion on the role of RH imaging in decision-making for treatment escalation in PAH. A panel of 17 physicians with expertise in PAH and RH imaging used three surveys in a modified Delphi process to reach consensus on the role of RH imaging in PAH. Survey 1 used open-ended questions to gather information. Survey 2 contained Likert scale and other questions intended to identify consensus on topics identified in Survey 1. Survey 3 contained Likert scale questions derived from Survey 2 and summary information on the results of Survey 2. The Delphi panel reached consensus that RH imaging is likely to improve the current risk stratification algorithms and help differentiate risk levels in patients at intermediate risk. Tricuspid annular plane systolic excursion, right ventricular fractional area change, right atrial area, tricuspid regurgitation, inferior venae cavae diameter, and pericardial effusion should be part of routine echocardiography in PAH. Cardiac magnetic resonance imaging is valuable but limited by cost and access. A pattern of abnormal RH imaging results should prompt consideration of hemodynamic evaluation and possible treatment escalation. RH imaging is an important tool for decisions about treatment escalation in PAH, but systematically collected evidence is needed to clarify its role.
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Affiliation(s)
- Paul Forfia
- Temple University HospitalPhiladelphiaPennsylvaniaUSA
| | | | | | - Teresa De Marco
- University of California, San FranciscoSan FranciscoCaliforniaUSA
| | | | | | | | - Ronald Oudiz
- Lundquist Institute for Biomedical Research at Harbor‐UCLA Medical CenterTorranceCaliforniaUSA
| | | | | | - John Ryan
- University of UtahSalt Lake CityUtahUSA
| | | | | | | | | | - Anton Vonk Noordegraaf
- Department of Pulmonary MedicineAmsterdam UMC location Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Amsterdam Cardiovascular SciencesPulmonary Hypertension and ThrombosisAmsterdamThe Netherlands
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5
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Karasu BB, Aydıncak HT. Right ventricular-pulmonary arterial uncoupling in mild-to-moderate asthma. J Asthma 2023; 60:543-552. [PMID: 35502969 DOI: 10.1080/02770903.2022.2073548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Persistent pulmonary hypertension and resulting right ventricular (RV) failure are highly encountered phenomenon in severe pulmonary diseases. However, in this study, we aimed to examine the effects of mild-to-moderate asthma on RV functions, pulmonary arterial stiffness (PAS), and coupling of RV to the pulmonary artery (PA) in the absence of overt pulmonary hypertension. METHODS We enrolled 53 patients with mild-to-moderate asthma, and 50 healthy control subjects. A comprehensive two dimensional transthoracic echocardiography was performed on each individual. The parameters measuring RV function were all examined. PAS was calculated by dividing maximal frequency shift of pulmonary flow by pulmonary acceleration time. RV-PA coupling was estimated by the tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) ratio (TAPSE/PASP). RESULTS Baseline demographics, clinical and laboratory parameters of both groups were similar (p > 0.05). Most of conventional echocardiographic parameters measuring RV function were impaired in patients with asthma compared to control subjects. PAS values were significantly higher in the asthma group [24 (21-26) vs. 20 (18-22), p < 0.001], and TAPSE/PASP ratio was significantly lower in the asthma group versus the control group [0.81 ± 0.08 vs. 0.96 ± 0.11, p < 0.001]. Multilinear regression analysis revealed PAS, TAPSE, and PASP as independent predictors of TAPSE/PASP ratio. CONCLUSION Mild-to-moderate asthma was shown to be associated with both subclinical RV dysfunction and increased PAS values. TAPSE/PASP ratio was also markedly decreased, suggesting RV-PA uncoupling even in the absence of overt pulmonary hypertension. PAS referring RV afterload was shown to be an independent predictor of TAPSE/PASP ratio.
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Affiliation(s)
- Betul Banu Karasu
- Department of Cardiology, Etimesgut Sehit Sait Erturk State Hospital, Ankara, Turkey
| | - Hatun Temel Aydıncak
- Department of Chest Diseases, Etimesgut Sehit Sait Erturk State Hospital, Ankara, Turkey
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6
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Bartnik A, Pepke-Zaba J, Hoole SP, White P, Garbi M, Coghlan JG, Taghavi F, Tsui S, Weir-McCall J. Right ventricular-pulmonary artery coupling in chronic thromboembolic pulmonary hypertension. Heart 2022; 109:898-904. [PMID: 36549680 DOI: 10.1136/heartjnl-2022-321770] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension occurs in a proportion of patients with prior acute pulmonary embolism and is characterised by breathlessness, persistently raised pulmonary pressures and right heart failure. Surgical pulmonary endarterectomy (PEA) offers significant prognostic and symptomatic benefits for patients with proximal disease distribution. For those with inoperable disease, management options include balloon pulmonary angioplasty (BPA) and medical therapy. Current clinical practice relies on the evaluation of pulmonary haemodynamics to assess disease severity, timing of and response to treatment. However, pulmonary haemodynamics correlate poorly with patient symptoms, which are influenced by right ventricular tolerance of the increased afterload. How best to manage symptomatic patients with chronic thromboembolic pulmonary disease (CTEPD) in the absence of pulmonary hypertension is not resolved.Right ventricular-pulmonary artery coupling (RV-PAC) describes the energy transfer within the whole cardiopulmonary unit. Thus, it can identify the earliest signs of decompensation even before pulmonary hypertension is overt. Invasive measurement of coupling using pressure volume loop technology is well established in research settings. The development of efficient and less invasive measurement methods has revived interest in coupling as a viable clinical tool. Significant improvement in RV-PAC has been demonstrated after both PEA and BPA. Further studies are required to understand its clinical utility and prognostic value, in particular, its potential to guide management in patients with CTEPD. Finally, given the reported differences in coupling between sexes in pulmonary arterial hypertension, further work is required to understand the applicability of proposed thresholds for decoupling in therapeutic decision making.
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Affiliation(s)
- Aleksandra Bartnik
- Radiology, Royal Papworth Hospital, Cambridge, UK .,University of Cambridge, Cambridge, UK.,Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Paul White
- Medical Physics and Clinical Engineering, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Medical Technology Research Centre, Anglia Ruskin University, Cambridge, UK
| | | | | | | | - Steven Tsui
- Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Jonathan Weir-McCall
- Radiology, Royal Papworth Hospital, Cambridge, UK.,University of Cambridge, Cambridge, UK
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7
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Rako ZA, Kremer N, Yogeswaran A, Richter MJ, Tello K. Adaptive versus maladaptive right ventricular remodelling. ESC Heart Fail 2022; 10:762-775. [PMID: 36419369 PMCID: PMC10053363 DOI: 10.1002/ehf2.14233] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/29/2022] [Accepted: 11/04/2022] [Indexed: 11/25/2022] Open
Abstract
Right ventricular (RV) function and its adaptation to increased afterload [RV-pulmonary arterial (PA) coupling] are crucial in various types of pulmonary hypertension, determining symptomatology and outcome. In the course of disease progression and increasing afterload, the right ventricle undergoes adaptive remodelling to maintain right-sided cardiac output by increasing contractility. Exhaustion of compensatory RV remodelling (RV-PA uncoupling) finally leads to maladaptation and increase of cardiac volumes, resulting in heart failure. The gold-standard measurement of RV-PA coupling is the ratio of contractility [end-systolic elastance (Ees)] to afterload [arterial elastance (Ea)] derived from RV pressure-volume loops obtained by conductance catheterization. The optimal Ees/Ea ratio is between 1.5 and 2.0. RV-PA coupling in pulmonary hypertension has considerable reserve; the Ees/Ea threshold at which uncoupling occurs is estimated to be ~0.7. As RV conductance catheterization is invasive, complex, and not widely available, multiple non-invasive echocardiographic surrogates for Ees/Ea have been investigated. One of the first described and best validated surrogates is the ratio of tricuspid annular plane systolic excursion to estimated pulmonary arterial systolic pressure (TAPSE/PASP), which has shown prognostic relevance in left-sided heart failure and precapillary pulmonary hypertension. Other RV-PA coupling surrogates have been formed by replacing TAPSE with different echocardiographic measures of RV contractility, such as peak systolic tissue velocity of the lateral tricuspid annulus (S'), RV fractional area change, speckle tracking-based RV free wall longitudinal strain and global longitudinal strain, and three-dimensional RV ejection fraction. PASP-independent surrogates have also been studied, including the ratios S'/RV end-systolic area index, RV area change/RV end-systolic area, and stroke volume/end-systolic volume. Limitations of these non-invasive surrogates include the influence of severe tricuspid regurgitation (which can cause distortion of longitudinal measurements and underestimation of PASP) and the angle dependence of TAPSE and PASP. Detection of early RV remodelling may require isolated analysis of single components of RV shortening along the radial and anteroposterior axes as well as the longitudinal axis. Multiple non-invasive methods may need to be applied depending on the level of RV dysfunction. This review explains the mechanisms of RV (mal)adaptation to its load, describes the invasive assessment of RV-PA coupling, and provides an overview of studies of non-invasive surrogate parameters, highlighting recently published works in this field. Further large-scale prospective studies including gold-standard validation are needed, as most studies to date had a retrospective, single-centre design with a small number of participants, and validation against gold-standard Ees/Ea was rarely performed.
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Affiliation(s)
- Zvonimir A. Rako
- Department of Internal Medicine Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL) Klinikstrasse 33 35392 Giessen Germany
| | - Nils Kremer
- Department of Internal Medicine Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL) Klinikstrasse 33 35392 Giessen Germany
| | - Athiththan Yogeswaran
- Department of Internal Medicine Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL) Klinikstrasse 33 35392 Giessen Germany
| | - Manuel J. Richter
- Department of Internal Medicine Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL) Klinikstrasse 33 35392 Giessen Germany
| | - Khodr Tello
- Department of Internal Medicine Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL) Klinikstrasse 33 35392 Giessen Germany
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8
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Boulate D, Loisel F, Coblence M, Provost B, Todesco A, Decante B, Beurnier A, Herve P, Perros F, Humbert M, Fadel E, Mercier O, Chemla D. Pulsatile pulmonary artery pressure in a large animal model of chronic thromboembolic pulmonary hypertension: Similarities and differences with human data. Pulm Circ 2022; 12:e12017. [PMID: 35506099 PMCID: PMC9052967 DOI: 10.1002/pul2.12017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 10/27/2021] [Accepted: 11/20/2021] [Indexed: 11/20/2022] Open
Abstract
A striking feature of the human pulmonary circulation is that mean (mPAP) and systolic (sPAP) pulmonary artery pressures (PAPs) are strongly related and, thus, are essentially redundant. According to the empirical formula documented under normotensive and hypertensive conditions (mPAP = 0.61 sPAP + 2 mmHg), sPAP matches ~160%mPAP on average. This attests to the high pulsatility of PAP, as also witnessed by the near equality of PA pulse pressure and mPAP. Our prospective study tested if pressure redundancy and high pulsatility also apply in a piglet model of chronic thromboembolic pulmonary hypertension (CTEPH). At baseline (Week‐0, W0), Sham (n = 8) and CTEPH (n = 27) had similar mPAP and stroke volume. At W6, mPAP increased in CTEPH only, with a two‐ to three‐fold increase in PA stiffness and total pulmonary resistance. Seven CTEPH piglets were also studied at W16 at baseline, after volume loading, and after acute pulmonary embolism associated with dobutamine infusion. There was a strong linear relationship between sPAP and mPAP (1) at W0 and W6 (n = 70 data points, r² = 0.95); (2) in the subgroup studied at W16 (n = 21, r² = 0.97); and (3) when all data were pooled (n = 91, r² = 0.97, sPAP range 9–112 mmHg). The PA pulsatility was lower than that expected based on observations in humans: sPAP matched ~120%mPAP only and PA pulse pressure was markedly lower than mPAP. In conclusion, the redundancy between mPAP and sPAP seems a characteristic of the pulmonary circulation independent of the species. However, it is suggested that the sPAP thresholds used to define PH in animals are species‐ and/or model‐dependent and thus must be validated.
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Affiliation(s)
- David Boulate
- Hôpital Marie Lannelongue INSERM UMR_S 999 Le Plessis Robinson France
| | - Fanny Loisel
- Hôpital Marie Lannelongue INSERM UMR_S 999 Le Plessis Robinson France
| | - Mathieu Coblence
- Hôpital Marie Lannelongue INSERM UMR_S 999 Le Plessis Robinson France
| | - Bastien Provost
- Hôpital Marie Lannelongue INSERM UMR_S 999 Le Plessis Robinson France
| | - Alban Todesco
- Hôpital Marie Lannelongue INSERM UMR_S 999 Le Plessis Robinson France
| | - Benoit Decante
- Hôpital Marie Lannelongue INSERM UMR_S 999 Le Plessis Robinson France
| | - Antoine Beurnier
- Hôpital Marie Lannelongue INSERM UMR_S 999 Le Plessis Robinson France
| | - Philippe Herve
- Hôpital Marie Lannelongue INSERM UMR_S 999 Le Plessis Robinson France
| | - Frédéric Perros
- Hôpital Marie Lannelongue INSERM UMR_S 999 Le Plessis Robinson France
| | - Marc Humbert
- Hôpital Marie Lannelongue INSERM UMR_S 999 Le Plessis Robinson France
- Service de Pneumologie, Hôpital Bicêtre DMU‐THORINO, AP‐HP Le Kremlin‐Bicêtre France
| | - Elie Fadel
- Hôpital Marie Lannelongue INSERM UMR_S 999 Le Plessis Robinson France
- Pôle Thoracique, Vasculaire et Transplantations Hôpital Marie Lannelongue Le Plessis Robinson France
| | - Olaf Mercier
- Hôpital Marie Lannelongue INSERM UMR_S 999 Le Plessis Robinson France
- Pôle Thoracique, Vasculaire et Transplantations Hôpital Marie Lannelongue Le Plessis Robinson France
| | - Denis Chemla
- Hôpital Marie Lannelongue INSERM UMR_S 999 Le Plessis Robinson France
- Service d'Explorations Fonctionnelles Multidisciplinaires Bi‐site, Hôpitaux Antoine Béclère–Kremlin Bicêtre, Faculté de médecine‐Université Paris Saclay DMU‐CORREVE, AP‐HP Le Kremlin‐Bicêtre France
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9
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de Perrot M, Gopalan D, Jenkins D, Lang IM, Fadel E, Delcroix M, Benza R, Heresi GA, Kanwar M, Granton JT, McInnis M, Klok FA, Kerr KM, Pepke-Zaba J, Toshner M, Bykova A, Armini AMD, Robbins IM, Madani M, McGiffin D, Wiedenroth CB, Mafeld S, Opitz I, Mercier O, Uber PA, Frantz RP, Auger WR. Evaluation and management of patients with chronic thromboembolic pulmonary hypertension - consensus statement from the ISHLT. J Heart Lung Transplant 2021; 40:1301-1326. [PMID: 34420851 DOI: 10.1016/j.healun.2021.07.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 07/22/2021] [Indexed: 02/08/2023] Open
Abstract
ISHLT members have recognized the importance of a consensus statement on the evaluation and management of patients with chronic thromboembolic pulmonary hypertension. The creation of this document required multiple steps, including the engagement of the ISHLT councils, approval by the Standards and Guidelines Committee, identification and selection of experts in the field, and the development of 6 working groups. Each working group provided a separate section based on an extensive literature search. These sections were then coalesced into a single document that was circulated to all members of the working groups. Key points were summarized at the end of each section. Due to the limited number of comparative trials in this field, the document was written as a literature review with expert opinion rather than based on level of evidence.
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Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Deepa Gopalan
- Department of Radiology, Imperial College Healthcare NHS Trust, London & Cambridge University Hospital, Cambridge, UK
| | - David Jenkins
- National Pulmonary Endarterectomy Service, Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Irene M Lang
- Department of Cardiology, Pulmonary Hypertension Unit, Medical University of Vienna, Vienna, Austria
| | - Elie Fadel
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Pulmonary Hypertension Centre, UZ Leuven, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU, Leuven, Belgium
| | - Raymond Benza
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - John T Granton
- Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | - Micheal McInnis
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Kim M Kerr
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK
| | - Mark Toshner
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK; Heart Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Anastasia Bykova
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Andrea M D' Armini
- Unit of Cardiac Surgery, Intrathoracic-Trasplantation and Pulmonary Hypertension, University of Pavia, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Ivan M Robbins
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Madani
- Department of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, California
| | - David McGiffin
- Department of Cardiothoracic Surgery, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Campus Kerckhoff of the University of Giessen, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Sebastian Mafeld
- Division of Vascular and Interventional Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Olaf Mercier
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Patricia A Uber
- Pauley Heart Center, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Robert P Frantz
- Department of Cardiovascular Disease, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - William R Auger
- Pulmonary Hypertension and CTEPH Research Program, Temple Heart and Vascular Institute, Temple University, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
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10
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Echocardiography in Pulmonary Arterial Hypertension: Is It Time to Reconsider Its Prognostic Utility? J Clin Med 2021; 10:jcm10132826. [PMID: 34206876 PMCID: PMC8268493 DOI: 10.3390/jcm10132826] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 12/26/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is characterized by an insult in the pulmonary vasculature, with subsequent right ventricular (RV) adaptation to the increased afterload that ultimately leads to RV failure. The awareness of the importance of RV function in PAH has increased considerably because right heart failure is the predominant cause of death in PAH patients. Given its wide availability and reduced cost, echocardiography is of paramount importance in the evaluation of the right heart in PAH. Several echocardiographic parameters have been shown to have prognostic implications in PAH; however, the role of echocardiography in the risk assessment of the PAH patient is limited under the current guidelines. This review discusses the echocardiographic evaluation of the RV in PAH and during therapy, and its prognostic implications, as well as the potential significant role of repeated echocardiographic assessment in the follow-up of patients with PAH.
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11
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Amsallem M, Bagherzadeh SP, Boulate D, Sweatt AJ, Kudelko KT, Sung YK, Feinstein JA, Fadel E, Mercier O, Denault A, Haddad F, Zamanian R. Hemodynamic trajectories and outcomes in patients with pulmonary arterial hypertension. Pulm Circ 2020; 10:2045894020941343. [PMID: 33335708 PMCID: PMC7724418 DOI: 10.1177/2045894020941343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 06/18/2020] [Indexed: 12/02/2022] Open
Abstract
The relative pulmonary to systemic pressure ratio (mean pulmonary arterial
pressure/mean arterial pressure) has been proven to be valuable in cardiac
surgery. Little is known on the prognostic value of baseline and trajectory of
mean pulmonary arterial pressure/mean arterial pressure in pulmonary arterial
hypertension. Patients with confirmed idiopathic, familial, drug and toxins, or
connective tissue disease-related pulmonary arterial hypertension and at least
one complete right heart catheterization were included and prospectively
followed-up for 5.9 ± 4.03 years. Correlates of the primary end point (i.e.
death or lung transplant need) during follow-up were determined using Cox
regression modeling. Results showed that among the 308 patients included, 187
had at least one follow-up catheterization (median time between
catheterizations: 2.16 (1.16–3.19) years). In the total cohort (mean age
47.3 ± 14.9 years, 82.8% of female and 58.1% in New York Heart Association class
3 or 4), mean pulmonary arterial pressure/mean arterial pressure (1.38
(1.07–1.77)) was associated with outcome (p = 0.01). Mean
pulmonary arterial pressure/mean arterial pressure was incremental to a basic
model (including right atrial pressure, systolic blood pressure, New York Heart
Association class 3 or 4, and connective tissue disease) for outcome prediction,
while mean pulmonary arterial pressure was not. In the 187 patients with a
follow-up catheterization, both delta mean pulmonary arterial pressure and delta
mean pulmonary arterial pressure/mean arterial pressure were associated with
outcome (1.32 (1.11–1.58) and 1.31 (1.1–1.57) respectively,
p < 0.01). Mean pulmonary arterial pressure and mean
pulmonary arterial pressure/mean arterial pressure were both incremental to the
basic model, while worsening in mean pulmonary arterial pressure or mean
pulmonary arterial pressure/mean arterial pressure did not reach significance.
In conclusion, mean pulmonary arterial pressure/mean arterial pressure at
baseline prognosticates long-term outcome with a significant, albeit modest,
incremental value to basic variables.
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Affiliation(s)
- Myriam Amsallem
- Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA.,Stanford Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | | | - David Boulate
- INSERM UMR S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Andrew J Sweatt
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA.,Vera Moulton Wall Center for Pulmonary Vascular Disease at Stanford, CA, USA
| | - Kristina T Kudelko
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA.,Vera Moulton Wall Center for Pulmonary Vascular Disease at Stanford, CA, USA
| | - Yon K Sung
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA.,Vera Moulton Wall Center for Pulmonary Vascular Disease at Stanford, CA, USA
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), and by courtesy Bioengineering, Stanford University, Stanford, CA, USA
| | - Elie Fadel
- INSERM UMR S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Olaf Mercier
- INSERM UMR S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Andre Denault
- Division of Anesthesiology and Critical Care, Université de Montréal, Montreal, QC, Canada
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA.,Stanford Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Roham Zamanian
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA.,Vera Moulton Wall Center for Pulmonary Vascular Disease at Stanford, CA, USA
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12
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Todaro MC, Carerj S, Zito C, Trifirò MP, Consolo G, Khandheria B. Echocardiographic evaluation of right ventricular-arterial coupling in pulmonary hypertension. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2020; 10:272-283. [PMID: 33224574 PMCID: PMC7675169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/24/2020] [Indexed: 06/11/2023]
Abstract
Pulmonary hypertension (PH) is a hemodynamic condition characterized by chronically elevated mean pulmonary artery pressure (m-PAP ≥ 25 mmHg) measured at rest by right heart catheterization (RHC). It includes a pre-capillary and a post-capillary form. Pulmonary artery hypertension (PAH) is a pre-capillary form of PH potentially generated by several heterogeneous systemic disorders, whose main hemodynamic change is represented by severely increased pulmonary vascular resistance (PVR). In order to preserve an efficient right ventricular-arterial (RV-PA) coupling, the right ventricle (RV) adapts to this chronic increase of its afterload, with a compensatory hypertrophy, until RV dilatation and dysfunction occur. Right ventricular (RV) function and especially RV-PA coupling assessment showed to be very important prognostic markers in this subset of patients, especially for those with pre-capillary PH. The aim of this review is to provide a pathophysiological insight into the spectrum of RV adaptive changes occurring in response to chronic increase of RV afterload and to present the role of echocardiographic parameters as possible tools for early non-invasive evaluation of RV-PA coupling, before overt heart failure ensues.
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Affiliation(s)
| | - Scipione Carerj
- Department of Clinical and Experimental Medicine - Cardiology Unit - University of MessinaMessina, Italy
| | - Concetta Zito
- Department of Clinical and Experimental Medicine - Cardiology Unit - University of MessinaMessina, Italy
| | | | | | - Bijoy Khandheria
- Aurora Research Institute, Aurora Health CareMilwaukee, WI, Italy
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13
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Dandel M, Javier MFDM, Javier Delmo EMD, Hetzer R. Accurate assessment of right heart function before and after long-term left ventricular assist device implantation. Expert Rev Cardiovasc Ther 2020; 18:289-308. [DOI: 10.1080/14779072.2020.1761790] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Michael Dandel
- Department of Cardiology, Cardio Centrum Berlin, Berlin, Germany
| | | | | | - Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany
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