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Oláh A, Barta BA, Ruppert M, Sayour AA, Nagy D, Bálint T, Nagy GV, Puskás I, Szente L, Szőcs L, Sohajda T, Zima E, Merkely B, Radovits T. A Comparative Investigation of the Pulmonary Vasodilating Effects of Inhaled NO Gas Therapy and Inhalation of a New Drug Formulation Containing a NO Donor Metabolite (SIN-1A). Int J Mol Sci 2024; 25:7981. [PMID: 39063223 PMCID: PMC11277253 DOI: 10.3390/ijms25147981] [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: 06/14/2024] [Revised: 07/15/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Numerous research projects focused on the management of acute pulmonary hypertension as Coronavirus Disease 2019 (COVID-19) might lead to hypoxia-induced pulmonary vasoconstriction related to acute respiratory distress syndrome. For that reason, inhalative therapeutic options have been the subject of several clinical trials. In this experimental study, we aimed to examine the hemodynamic impact of the inhalation of the SIN-1A formulation (N-nitroso-N-morpholino-amino-acetonitrile, the unstable active metabolite of molsidomine, stabilized by a cyclodextrin derivative) in a porcine model of acute pulmonary hypertension. Landrace pigs were divided into the following experimental groups: iNO (inhaled nitric oxide, n = 3), SIN-1A-5 (5 mg, n = 3), and SIN-1A-10 (10 mg, n = 3). Parallel insertion of a PiCCO system and a pulmonary artery catheter (Swan-Ganz) was performed for continuous hemodynamic monitoring. The impact of iNO (15 min) and SIN-1A inhalation (30 min) was investigated under physiologic conditions and U46619-induced acute pulmonary hypertension. Mean pulmonary arterial pressure (PAP) was reduced transiently by both substances. SIN-1A-10 had a comparable impact compared to iNO after U46619-induced pulmonary hypertension. PAP and PVR decreased significantly (changes in PAP: -30.1% iNO, -22.1% SIN-1A-5, -31.2% SIN-1A-10). While iNO therapy did not alter the mean arterial pressure (MAP) and systemic vascular resistance (SVR), SIN-1A administration resulted in decreased MAP and SVR values. Consequently, the PVR/SVR ratio was markedly reduced in the iNO group, while SIN-1A did not alter this parameter. The pulmonary vasodilatory impact of inhaled SIN-1A was shown to be dose-dependent. A larger dose of SIN-1A (10 mg) resulted in decreased PAP and PVR in a similar manner to the gold standard iNO therapy. Inhalation of the nebulized solution of the new SIN-1A formulation (stabilized by a cyclodextrin derivative) might be a valuable, effective option where iNO therapy is not available due to dosing difficulties or availability.
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Affiliation(s)
- Attila Oláh
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Bálint András Barta
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Mihály Ruppert
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Alex Ali Sayour
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Dávid Nagy
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Tímea Bálint
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Georgina Viktória Nagy
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | | | | | | | | | - Endre Zima
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
| | - Tamás Radovits
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary (D.N.); (T.B.); (E.Z.); (B.M.)
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Benedetto M, Piccone G, Gottin L, Castelli A, Baiocchi M. Inhaled Pulmonary Vasodilators for the Treatment of Right Ventricular Failure in Cardio-Thoracic Surgery: Is One Better than the Others? J Clin Med 2024; 13:564. [PMID: 38256697 PMCID: PMC10816998 DOI: 10.3390/jcm13020564] [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: 11/20/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
Right ventricular failure (RFV) is a potential complication following cardio-thoracic surgery, with an incidence ranging from 0.1% to 30%. The increase in pulmonary vascular resistance (PVR) is one of the main triggers of perioperative RVF. Inhaled pulmonary vasodilators (IPVs) can reduce PVR and improve right ventricular function with minimal systemic effects. This narrative review aims to assess the efficacy of inhaled nitric oxide and inhaled prostacyclins for the treatment of perioperative RVF. The literature, although statistically limited, supports the clinical similarity between them. However, it failed to demonstrate a clear benefit from the pre-emptive use of inhaled nitric oxide in patients undergoing left ventricular assist device implantation or early administration during heart-lung transplants. Additional concerns are related to cost safety and IPV use in pathologies associated with pulmonary venous congestion. The largest ongoing randomized controlled trial on adults (INSPIRE-FLO) is addressing whether inhaled Epoprostenol and inhaled nitric oxide are similar in preventing RVF after heart transplants and left ventricular assist device placement, and whether they are similar in preventing primary graft dysfunction after lung transplants. The preliminary analysis supports their equivalence. Several key points may be achieved by the present narrative review. When RVF occurs in the setting of elevated PVR, IPV should be the preferred initial treatment and they should be preventively used in patients at high risk of postoperative RVF. If severe refractory postoperative RVF occurs, IPVs should be combined with complementary pharmacology (inotropes and inodilators). If unsuccessful, right ventricular mechanical support should be established.
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Affiliation(s)
- Maria Benedetto
- Cardio-Thoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (M.B.)
| | - Giulia Piccone
- Cardiothoracic and Vascular Intensive Care Unit, Hospital and University Trust of Verona, P. le A. Stefani, 37124 Verona, Italy; (G.P.); (L.G.)
| | - Leonardo Gottin
- Cardiothoracic and Vascular Intensive Care Unit, Hospital and University Trust of Verona, P. le A. Stefani, 37124 Verona, Italy; (G.P.); (L.G.)
| | - Andrea Castelli
- Cardio-Thoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (M.B.)
| | - Massimo Baiocchi
- Cardio-Thoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (M.B.)
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Ghadimi K, Cappiello JL, Wright MC, Levy JH, Bryner BS, DeVore AD, Schroder JN, Patel CB, Rajagopal S, Shah SH, Milano CA. Inhaled Epoprostenol Compared With Nitric Oxide for Right Ventricular Support After Major Cardiac Surgery. Circulation 2023; 148:1316-1329. [PMID: 37401479 PMCID: PMC10615678 DOI: 10.1161/circulationaha.122.062464] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 06/06/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Right ventricular failure (RVF) is a leading driver of morbidity and death after major cardiac surgery for advanced heart failure, including orthotopic heart transplantation and left ventricular assist device implantation. Inhaled pulmonary-selective vasodilators, such as inhaled epoprostenol (iEPO) and nitric oxide (iNO), are essential therapeutics for the prevention and medical management of postoperative RVF. However, there is limited evidence from clinical trials to guide agent selection despite the significant cost considerations of iNO therapy. METHODS In this double-blind trial, participants were stratified by assigned surgery and key preoperative prognostic features, then randomized to continuously receive either iEPO or iNO beginning at the time of separation from cardiopulmonary bypass with the continuation of treatment into the intensive care unit stay. The primary outcome was the composite RVF rate after both operations, defined after transplantation by the initiation of mechanical circulatory support for isolated RVF, and defined after left ventricular assist device implantation by moderate or severe right heart failure according to criteria from the Interagency Registry for Mechanically Assisted Circulatory Support. An equivalence margin of 15 percentage points was prespecified for between-group RVF risk difference. Secondary postoperative outcomes were assessed for treatment differences and included: mechanical ventilation duration; hospital and intensive care unit length of stay during the index hospitalization; acute kidney injury development including renal replacement therapy initiation; and death at 30 days, 90 days, and 1 year after surgery. RESULTS Of 231 randomized participants who met eligibility at the time of surgery, 120 received iEPO, and 111 received iNO. Primary outcome occurred in 30 participants (25.0%) in the iEPO group and 25 participants (22.5%) in the iNO group, for a risk difference of 2.5 percentage points (two one-sided test 90% CI, -6.6% to 11.6%) in support of equivalence. There were no significant between-group differences for any of the measured postoperative secondary outcomes. CONCLUSIONS Among patients undergoing major cardiac surgery for advanced heart failure, inhaled pulmonary-selective vasodilator treatment using iEPO was associated with similar risks for RVF development and development of other postoperative secondary outcomes compared with treatment using iNO. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03081052.
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Affiliation(s)
- Kamrouz Ghadimi
- Department of Anesthesiology, Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, and the Clinical Research Unit (K.G., M.C.W., J.H.L.), Duke University School of Medicine, Durham, NC
| | | | - Mary Cooter Wright
- Department of Anesthesiology, Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, and the Clinical Research Unit (K.G., M.C.W., J.H.L.), Duke University School of Medicine, Durham, NC
| | - Jerrold H Levy
- Department of Anesthesiology, Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, and the Clinical Research Unit (K.G., M.C.W., J.H.L.), Duke University School of Medicine, Durham, NC
- Department of Surgery, Adult Cardiac Surgery Section (J.H.L., B.S.B., J.N.S., C.A.M.), Duke University School of Medicine, Durham, NC
| | - Benjamin S Bryner
- Department of Surgery, Adult Cardiac Surgery Section (J.H.L., B.S.B., J.N.S., C.A.M.), Duke University School of Medicine, Durham, NC
| | - Adam D DeVore
- Department of Medicine, Division of Cardiology (A.D.D., C.B.P., S.R., S.H.S.), Duke University School of Medicine, Durham, NC
| | - Jacob N Schroder
- Department of Surgery, Adult Cardiac Surgery Section (J.H.L., B.S.B., J.N.S., C.A.M.), Duke University School of Medicine, Durham, NC
| | - Chetan B Patel
- Department of Medicine, Division of Cardiology (A.D.D., C.B.P., S.R., S.H.S.), Duke University School of Medicine, Durham, NC
| | - Sudarshan Rajagopal
- Department of Medicine, Division of Cardiology (A.D.D., C.B.P., S.R., S.H.S.), Duke University School of Medicine, Durham, NC
| | - Svati H Shah
- Department of Medicine, Division of Cardiology (A.D.D., C.B.P., S.R., S.H.S.), Duke University School of Medicine, Durham, NC
| | - Carmelo A Milano
- Department of Surgery, Adult Cardiac Surgery Section (J.H.L., B.S.B., J.N.S., C.A.M.), Duke University School of Medicine, Durham, NC
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Ghadimi K, Cappiello J, Cooter-Wright M, Haney JC, Reynolds JM, Bottiger BA, Klapper JA, Levy JH, Hartwig MG. Inhaled Pulmonary Vasodilator Therapy in Adult Lung Transplant: A Randomized Clinical Trial. JAMA Surg 2021; 157:e215856. [PMID: 34787647 DOI: 10.1001/jamasurg.2021.5856] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Inhaled nitric oxide (iNO) is commonly administered for selectively inhaled pulmonary vasodilation and prevention of oxidative injury after lung transplant (LT). Inhaled epoprostenol (iEPO) has been introduced worldwide as a cost-saving alternative to iNO without high-grade evidence for this indication. Objective To investigate whether the use of iEPO will lead to similar rates of severe/grade 3 primary graft dysfunction (PGD-3) after adult LT when compared with use of iNO. Design, Setting, and Participants This health system-funded, randomized, blinded (to participants, clinicians, data managers, and the statistician), parallel-designed, equivalence clinical trial included 201 adult patients who underwent single or bilateral LT between May 30, 2017, and March 21, 2020. Patients were grouped into 5 strata according to key prognostic clinical features and randomized per stratum to receive either iNO or iEPO at the time of LT via 1:1 treatment allocation. Interventions Treatment with iNO or iEPO initiated in the operating room before lung allograft reperfusion and administered continously until cessation criteria met in the intensive care unit (ICU). Main Outcomes and Measures The primary outcome was PGD-3 development at 24, 48, or 72 hours after LT. The primary analysis was for equivalence using a two one-sided test (TOST) procedure (90% CI) with a margin of 19% for between-group PGD-3 risk difference. Secondary outcomes included duration of mechanical ventilation, hospital and ICU lengths of stay, incidence and severity of acute kidney injury, postoperative tracheostomy placement, and in-hospital, 30-day, and 90-day mortality rates. An intention-to-treat analysis was performed for the primary and secondary outcomes, supplemented by per-protocol analysis for the primary outcome. Results A total of 201 randomized patients met eligibility criteria at the time of LT (129 men [64.2%]). In the intention-to-treat population, 103 patients received iEPO and 98 received iNO. The primary outcome occurred in 46 of 103 patients (44.7%) in the iEPO group and 39 of 98 (39.8%) in the iNO group, leading to a risk difference of 4.9% (TOST 90% CI, -6.4% to 16.2%; P = .02 for equivalence). There were no significant between-group differences for secondary outcomes. Conclusions and Relevance Among patients undergoing LT, use of iEPO was associated with similar risks for PGD-3 development and other postoperative outcomes compared with the use of iNO. Trial Registration ClinicalTrials.gov identifier: NCT03081052.
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Affiliation(s)
- Kamrouz Ghadimi
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Jhaymie Cappiello
- Department of Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
| | - Mary Cooter-Wright
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - John C Haney
- Department of Surgery, Thoracic Transplant Surgery, Duke University School of Medicine, Durham, North Carolina
| | - John M Reynolds
- Department of Medicine, Transplant Pulmonology, Duke University School of Medicine, Durham, North Carolina
| | - Brandi A Bottiger
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Jacob A Klapper
- Department of Surgery, Thoracic Transplant Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Jerrold H Levy
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Matthew G Hartwig
- Department of Surgery, Thoracic Transplant Surgery, Duke University School of Medicine, Durham, North Carolina
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Abstract
Purpose of review Heart failure with preserved ejection fraction (HFpEF) is a complex and heterogeneous condition of multiple causes, characterized by a clinical syndrome resulting from elevated left ventricular filling pressures, with an apparently unimpaired left ventricular systolic function. Although HFpEF has been long recognized as a distinct entity with significant morbidity for patients, its diagnosis remains challenging to this day. In recent years, few diagnostic algorithms have been postulated to aid in the identification of this condition. Invasive hemodynamic and metabolic evaluation is often warranted for the conclusive diagnosis and risk stratification of HFpEF, in patients presenting with undifferentiated DOE. Recent findings Rest and provoked hemodynamics remain the golden-standard diagnostic tool to unequivocally confirm the diagnosis of both established and incipient HFpEF, respectively. Cycle exercise hemodynamics is the paramount provocative maneuver to unveil this condition. Rapid saline loading does not offer a significant benefit over that of cycle exercise. Vasoactive agents can also uncover and confirm incipient HFpEF disease. The role of metabolic evaluation in patients presenting with idiopathic dyspnea on exertion (DOE) is of unparalleled value for those who have expertise in cardiopulmonary exercise test (CPET) interpretation; however, the average clinician who focuses solely on oxygen consumption will find it underwhelming. Invasive CPET stands alone as the ultimate diagnostic tool to discriminate between pulmonary, cardiovascular, and skeletal muscle disorders, and their respective contribution to DOE and exercise intolerance. Summary Several hemodynamic and metabolic parameters have demonstrated not only strong diagnostic value, but also predictive power in HFpEF. Additionally, these diagnostic methods have given rise to several therapeutic interventions that are now part of our clinical armamentarium. Regrettably, due to the heterogeneity and multicausality of HFpEF, none of the targeted interventions have been so far successful in decreasing the mortality burden of this prevalent condition.
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Lui JK, Mesfin N, Tugal D, Klings ES, Govender P, Berman JS. Critical Care of Patients With Cardiopulmonary Complications of Sarcoidosis. J Intensive Care Med 2021; 37:441-458. [PMID: 33611981 DOI: 10.1177/0885066621993041] [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: 11/16/2022]
Abstract
Sarcoidosis is a systemic inflammatory disease defined by the presence of aberrant granulomas affecting various organs. Due to its multisystem involvement, care of patients with established sarcoidosis becomes challenging, especially in the intensive care setting. While the lungs are typically involved, extrapulmonary manifestations also occur either concurrently or exclusively within a significant proportion of patients, complicating diagnostic and management decisions. The scope of this review is to focus on what considerations are necessary in the evaluation and management of patients with known sarcoidosis and their associated complications within a cardiopulmonary and critical care perspective.
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Affiliation(s)
- Justin K Lui
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA.,Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Nathan Mesfin
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA.,Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Derin Tugal
- Section of Cardiovascular Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Elizabeth S Klings
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA.,Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Praveen Govender
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA.,Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jeffrey S Berman
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA.,Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Boston University School of Medicine, Boston, MA, USA
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Keshavarz A, Kadry H, Alobaida A, Ahsan F. Newer approaches and novel drugs for inhalational therapy for pulmonary arterial hypertension. Expert Opin Drug Deliv 2020; 17:439-461. [PMID: 32070157 DOI: 10.1080/17425247.2020.1729119] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Pulmonary arterial hypertension (PAH) is a progressive disease characterized by remodeling of small pulmonary arteries leading to increased pulmonary arterial pressure. Existing treatments acts to normalize vascular tone via three signaling pathways: the prostacyclin, the endothelin-1, and the nitric oxide. Although over the past 20 years, there has been considerable progress in terms of treatments for PAH, the disease still remains incurable with a disappointing prognosis.Areas covered: This review summarizes the pathophysiology of PAH, the advantages and disadvantages of the inhalation route, and assess the relative advantages various inhaled therapies for PAH. The recent studies concerning the development of controlled-release drug delivery systems loaded with available anti-PAH drugs have also been summarized.Expert opinion: The main obstacles of current pharmacotherapies of PAH are their short half-life, stability, and formulations, resulting in reducing the efficacy and increasing systemic side effects and unknown pathogenesis of PAH. The pulmonary route has been proposed for delivering anti-PAH drugs to overcome the shortcomings. However, the application of approved inhaled anti-PAH drugs is limited. Inhalational delivery of controlled-release nanoformulations can overcome these restrictions. Extensive studies are required to develop safe and effective drug delivery systems for PAH patients.
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Affiliation(s)
- Ali Keshavarz
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - Hossam Kadry
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - Ahmed Alobaida
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - Fakhrul Ahsan
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX, USA
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Stene Hurtsén A, Zorikhin Nilsson I, Dogan EM, Nilsson KF. A Comparative Study of Inhaled Nitric Oxide and an Intravenously Administered Nitric Oxide Donor in Acute Pulmonary Hypertension. DRUG DESIGN DEVELOPMENT AND THERAPY 2020; 14:635-645. [PMID: 32109989 PMCID: PMC7034972 DOI: 10.2147/dddt.s237477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/21/2020] [Indexed: 12/20/2022]
Abstract
Purpose Inhaled nitric oxide (iNO) selectively vasodilates the pulmonary circulation but the effects are sometimes insufficient. Available intravenous (iv) substances are non-selective and cause systemic side effects. The pulmonary and systemic effects of iNO and an iv mono-organic nitrite (PDNO) were compared in porcine models of acute pulmonary hypertension. Methods In anesthetized piglets, dose–response experiments of iv PDNO at normal pulmonary arterial pressure (n=10) were executed. Dose–response experiments of iv PDNO (n=6) and iNO (n=7) were performed during pharmacologically induced pulmonary hypertension (U46619 iv). The effects of iv PDNO and iNO were also explored in 5 mins of hypoxia-induced increase in pulmonary pressure (n=2-4). Results PDNO (15, 30, 45 and 60 nmol NO kg−1 min−1 iv) and iNO (5, 10, 20 and 40 ppm which corresponded to 56, 112, 227, 449 nmol NO kg−1 min−1, respectively) significantly decreased the U46619-increased mean pulmonary arterial pressure (MPAP) and pulmonary vascular resistance (PVR) to a similar degree without significant decreases in mean arterial pressure (MAP) or systemic vascular resistance (SVR). iNO caused increased levels of methemoglobin. At an equivalent delivered NO quantity (iNO 5 ppm and PDNO 45 nmol kg−1 min−1 iv), PDNO decreased PVR and SVR significantly more than iNO. Both drugs counteracted hypoxia-induced pulmonary vasoconstriction and they decreased the ratio of PVR and SVR in both settings. Conclusion Intravenous PDNO was a more potent pulmonary vasodilator than iNO in pulmonary hypertension, with no severe side effects. Hence, this study supports the potential of iv PDNO in the treatment of acute pulmonary hypertension.
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Affiliation(s)
- Anna Stene Hurtsén
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Centre for Clinical Research and Education, Karlstad Central Hospital, Karlstad, Sweden
| | - Ilya Zorikhin Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Emanuel M Dogan
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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The Clinical Impact of Flow Titration on Epoprostenol Delivery via High Flow Nasal Cannula for ICU Patients with Pulmonary Hypertension or Right Ventricular Dysfunction: A Retrospective Cohort Comparison Study. J Clin Med 2020; 9:jcm9020464. [PMID: 32046152 PMCID: PMC7074129 DOI: 10.3390/jcm9020464] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/28/2020] [Accepted: 02/04/2020] [Indexed: 01/09/2023] Open
Abstract
(1) Background: inhaled epoprostenol (iEPO) delivered via high-flow nasal cannula (HFNC) has been reported to be effective for pulmonary hypertension and right ventricular dysfunction. In vitro studies have identified HFNC gas flow as a key factor in trans-nasal aerosol delivery efficiency; however, little evidence is available on the clinical impact of flow titration on trans-nasal aerosol delivery. At our institution, iEPO via HFNC was initiated in 2015 and the concept of flow titration during iEPO via HFNC has been gradually accepted and carried out by clinicians in the recent years. (2) Methods: a retrospective review of the electronic medical records for all adult patients who received iEPO via HFNC in a tertiary teaching hospital. Pre- and post- iEPO responses were reported for patients whose HFNC flow was titrated or maintained constant during iEPO delivery. Positive response to iEPO was defined as the reduction of mean pulmonary arterial pressure (mPAP) > 10% for pulmonary hypertension patients or the improvement of oxygenation [pulse oximetry (SpO2)/fraction of inhaled oxygen (FIO2)] > 20%. The number of responders to iEPO was compared between groups with titrated vs constant flow. (3) Results: 51 patients who used iEPO to treat pulmonary hypertension and/or right ventricular dysfunction were reviewed. Following iEPO administration via HFNC, mPAP decreased (43.6 ± 11.7 vs. 36.3 ± 9.7 mmHg, p < 0.001). Among the 51 patients, 24 had concomitant refractory hypoxemia, their oxygenation (SpO2/FIO2) improved after iEPO delivery (127.8 ± 45.7 vs. 157.6 ± 62.2, p < 0.001). During iEPO initiation, gas flow was titrated in 25 patients and the remaining 26 patients used constant flow. The percentage of patients in the flow titration group who met the criteria for a positive response was higher compared to the group with constant flow (85.7% vs. 50%, p = 0.035). Pre- vs post-iEPO responses were significant in the flow titration group included improvement in cardiac output (p = 0.050), cardiac index (p = 0.021) and FIO2 reduction (p = 0.016). These improvements in hemodynamics and FIO2 were not observed in the constant flow group. (4) Conclusion: in patients with pulmonary hypertension and/or right ventricular dysfunction, trans-nasal iEPO decreased pulmonary arterial pressure. It also improved oxygenation in patients with combined refractory hypoxemia. These improvements were more evident in patients whose gas flow was titrated during iEPO initiation than those patients using constant flow.
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Huis in’t Veld AE, Oosterveer FP, De man FS, Marcus JTIM, Nossent EJ, Boonstra A, Van rossum A(B, Vonk Noordegraaf A, Bogaard HJ, Handoko ML. Hemodynamic Effects of Pulmonary Arterial Hypertension-Specific Therapy in Patients With Heart Failure With Preserved Ejection Fraction and With Combined Post- and Precapillay Pulmonary Hypertension. J Card Fail 2020; 26:26-34. [DOI: 10.1016/j.cardfail.2019.07.547] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 07/21/2019] [Accepted: 07/26/2019] [Indexed: 12/22/2022]
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Li J, Harnois LJ, Markos B, Roberts KM, Homoud SA, Liu J, Mirza S, Vines D. Epoprostenol Delivered via High Flow Nasal Cannula for ICU Subjects with Severe Hypoxemia Comorbid with Pulmonary Hypertension or Right Heart Dysfunction. Pharmaceutics 2019; 11:pharmaceutics11060281. [PMID: 31207936 PMCID: PMC6631264 DOI: 10.3390/pharmaceutics11060281] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/06/2019] [Accepted: 06/10/2019] [Indexed: 12/20/2022] Open
Abstract
Inhaled epoprostenol (iEPO) has been utilized to improve oxygenation in mechanically ventilated subjects with severe hypoxemia, but the evidence for iEPO via high-flow nasal cannula (HFNC) is rare. Following approval by the institutional review board, this retrospective cohort study evaluated subjects who received iEPO via HFNC for more than 30 min to treat severe hypoxemia comorbid with pulmonary hypertension or right heart dysfunction between July 2015 and April 2018. A total of 11 subjects were enrolled in the study of whom 4 were male (36.4%), age 57.5 ± 22.1 years, and APACHE II score at ICU admission was 18.5 ± 5.7. Ten subjects had more than three chronic heart or lung comorbidities; seven of them used home oxygen. After inhaling epoprostenol, subjects' SpO2/FIO2 ratio improved from 107.5 ± 26.3 to 125.5 ± 31.6 (p = 0.026) within 30-60 min. Five subjects (45.5%) had SpO2/FIO2 improvement >20%, which was considered as a positive response. Heart rate, blood pressure, and respiratory rate were not significantly different. Seven subjects did not require intubation, and seven subjects were discharged home. This retrospective study demonstrated the feasibility of iEPO via HFNC in improving oxygenation. Careful titration of flow while evaluating subjects' response may help identify responders and avoid delaying other interventions. This study supports the need for a larger prospective randomized control trial to further evaluate the efficacy of iEPO via HFNC in improving outcomes.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Lauren J Harnois
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Bethelhem Markos
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Keith M Roberts
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Salma Al Homoud
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Jing Liu
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - Sara Mirza
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
| | - David Vines
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL 60130, USA.
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12
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Domingo E, Grignola JC, Trujillo P, Aguilar R, Roman A. Proximal pulmonary arterial wall disease in patients with persistent pulmonary hypertension after successful left-sided valve replacement according to the hemodynamic phenotype. Pulm Circ 2018; 9:2045894018816972. [PMID: 30430894 PMCID: PMC6295709 DOI: 10.1177/2045894018816972] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Regression of pulmonary hypertension (PH) is often incomplete after successful left-sided valve replacement (LSVR). Proximal pulmonary arterial (PPA) wall disease can be involved in patients with persistent-PH after LSVR, affecting the right ventricular to pulmonary arterial (RV-PA) coupling. Fifteen patients underwent successful LSVR at least one year ago presenting PH by echo (> 50 mmHg). Prosthesis-patient mismatch and left ventricular dysfunction were discarded. All patients underwent hemodynamic and intravascular ultrasound (IVUS) study. We estimated PPA stiffness (elastic modulus [EM]) and the relative area wall thickness (AWT). Acute vasoreactivity was assessed by inhaled nitric oxide (iNO) testing. RV-PA coupling was estimated by the tricuspid annular plane systolic excursion to systolic pulmonary arterial pressure ratio. Patients were classified as isolated post-capillary PH (Ipc-PH; pulmonary vascular resistance [PVR] ≤ 3 WU and/or diastolic pulmonary gradient [DPG] < 7 mmHg) and combined post- and pre-capillary PH (Cpc-PH; PVR > 3 WU and DPG ≥ 7 mmHg). Both Ipc-PH and Cpc-PH showed a significant increase of EM and AWT. Despite normal PVR and DPG, Ipc-PH had a significant decrease in pulmonary arterial capacitance and RV-PA coupling impairment. Cpc-PH had worse PA stiffness and RV-PA coupling to Ipc-PH ( P < 0.05). iNO decreased RV afterload, improving the cardiac index and stroke volume only in Cpc-PH ( P < 0.05). Patients with persistent PH after successful LSVR have PPA wall disease and RV-PA coupling impairment beyond the hemodynamic phenotype. Cpc-PH is responsive to iNO, having the worse PA stiffness and RV-PA coupling. The PPA remodeling could be an early event in the natural history of PH associated with left heart disease.
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Affiliation(s)
- Enric Domingo
- 1 Area del Cor, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,2 Physiology Department, School of Medicine, Universitat Autonoma, Barcelona, Spain
| | - Juan C Grignola
- 3 Pathophysiology Department, Facultad de Medicina, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Pedro Trujillo
- 4 Cardiology Department, Centro Cardiovascular Universitario, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Rio Aguilar
- 5 Cardiology Department, Hospital de la Princesa, Madrid, Spain
| | - Antonio Roman
- 6 Department of Neumology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,7 Ciberes, IS Carlos III, Madrid, Spain
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13
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Elinoff JM, Agarwal R, Barnett CF, Benza RL, Cuttica MJ, Gharib AM, Gray MP, Hassoun PM, Hemnes AR, Humbert M, Kolb TM, Lahm T, Leopold JA, Mathai SC, McLaughlin VV, Preston IR, Rosenzweig EB, Shlobin OA, Steen VD, Zamanian RT, Solomon MA. Challenges in Pulmonary Hypertension: Controversies in Treating the Tip of the Iceberg. A Joint National Institutes of Health Clinical Center and Pulmonary Hypertension Association Symposium Report. Am J Respir Crit Care Med 2018; 198:166-174. [PMID: 29425462 PMCID: PMC6058980 DOI: 10.1164/rccm.201710-2093pp] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/09/2018] [Indexed: 01/13/2023] Open
Affiliation(s)
| | - Richa Agarwal
- Division of Cardiovascular Disease, Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | | | - Raymond L. Benza
- Division of Cardiovascular Disease, Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Michael J. Cuttica
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ahmed M. Gharib
- National Institute of Diabetes, Digestive, and Kidney Diseases, and
| | | | - Paul M. Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marc Humbert
- Service de Pneumologie, Hôpital Bicêtre (Assistance Publique–Hôpitaux de Paris), Institut National de la Santé et de la Recherche Médicale U999, University Paris–Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Todd M. Kolb
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Tim Lahm
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Indiana University, Indianapolis, Indiana
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Jane A. Leopold
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Vallerie V. McLaughlin
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ioana R. Preston
- Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | | | - Oksana A. Shlobin
- Pulmonary Vascular Disease Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Virginia D. Steen
- Rheumatology Division, Department of Medicine, Georgetown University, Washington, DC; and
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14
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Gerges C, Gerges M, Fesler P, Pistritto AM, Konowitz NP, Jakowitsch J, Celermajer DS, Lang I. In-depth haemodynamic phenotyping of pulmonary hypertension due to left heart disease. Eur Respir J 2018; 51:13993003.00067-2018. [DOI: 10.1183/13993003.00067-2018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/10/2018] [Indexed: 12/22/2022]
Abstract
The commonest cause of pulmonary hypertension (PH) is left heart disease (LHD). The current classification system for definitions of PH-LHD is under review. We therefore performed prospective in-depth invasive haemodynamic phenotyping in order to assess the site of increased pulmonary vascular resistance (PVR) in PH-LHD subsets.Based on pulmonary artery occlusion waveforms yielding an estimate of the effective capillary pressure, we partitioned PVR in larger arterial (Rup, upstream resistance) and small arterial plus venous components (Rds, downstream resistance). In the case of small vessel disease, Rup decreases and Rds increases. Inhaled nitric oxide (NO) testing was used to assess acute vasoreactivity.Right ventricular afterload (PVR, pulmonary arterial compliance and effective arterial elastance) was significantly higher in combined post- and pre-capillary PH (Cpc-PH, n=35) than in isolated post-capillary PH (Ipc-PH, n=20). Right ventricular afterload decreased during inhalation of NO in Cpc-PH and idiopathic pulmonary arterial hypertension (n=31), but remained unchanged in Ipc-PH. Rup was similar in Cpc-PH (66.8±10.8%) and idiopathic pulmonary arterial hypertension (65.0±12.2%; p=0.530) suggesting small vessel disease, but significantly higher in Ipc-PH (96.5±4.5%; p<0.001) suggesting upstream transmission of elevated left atrial pressure.Right ventricular afterload is driven by elevated left atrial pressure in Ipc-PH and is further increased by elevated small vessel resistance in Cpc-PH. Cpc-PH is responsive to inhaled NO. Our data support current definitions of PH-LHD subsets.
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15
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Invasive Hemodynamic Assessment of Patients with Heart Failure and Pulmonary Hypertension. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:40. [PMID: 28466117 DOI: 10.1007/s11936-017-0544-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OPINION STATEMENT Right heart catheterization (RHC) with a pulmonary artery (PA) catheter is a minimally invasive method of obtaining hemodynamic data (e.g., right atrial and pulmonary pressures, cardiac output, pulmonary vascular resistance), which are used to diagnose and manage patients with advanced heart failure (HF), HF with preserved ejection fraction, and pulmonary hypertension (PH). Invasive hemodynamic data obtained from RHC can aid in the prognostication of HF and PH patients and are important in guiding decisions of implanting mechanical circulatory support devices and listing patients for heart and/or lung transplantation. The basis of RHC has also paved the way for implantable hemodynamic devices to monitor pulmonary artery pressures in the outpatient setting, which can reduce rates of HF-related hospitalizations. We will discuss the utility of PA catheters in the diagnosis and management of the aforementioned disease states, the role of implantable hemodynamic monitors, and the complications associated with RHC procedures.
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16
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Fritz JS, Smith KA. The Pulmonary Hypertension Consult: Clinical and Coding Considerations. Chest 2016; 150:705-13. [PMID: 27189309 DOI: 10.1016/j.chest.2016.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 04/12/2016] [Accepted: 05/05/2016] [Indexed: 10/21/2022] Open
Abstract
Pulmonary hypertension (PH) is an increasingly recognized cause of morbidity and mortality, and in the past 20 years, there has been a rapid expansion in research and available therapies. Although it is defined quite simply as a mean pulmonary arterial pressure of ≥ 25 mm Hg, PH encompasses a heterogeneous group of disease processes. In the past, PH was classified as primary or secondary, but as understanding of the various contributing diseases has increased, classification systems have attempted to group these diseases by clinical features and disease mechanism. The evaluation of patients with suspected PH can be cumbersome, and a careful and methodical approach is needed to ensure timely and accurate diagnosis, correct physiological classification, and appropriate treatment. In this review, we discuss the classification and diagnostic evaluation of PH in adults as well as some of the billing and coding considerations involved in this evaluation.
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Affiliation(s)
- Jason S Fritz
- Department of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - K Akaya Smith
- Department of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Al-Naamani N, Preston IR, Paulus JK, Hill NS, Roberts KE. Pulmonary Arterial Capacitance Is an Important Predictor of Mortality in Heart Failure With a Preserved Ejection Fraction. JACC-HEART FAILURE 2016; 3:467-474. [PMID: 26046840 DOI: 10.1016/j.jchf.2015.01.013] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 01/09/2015] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The purpose of this study was to determine the predictors of mortality in patients with pulmonary hypertension (PH) associated with heart failure with preserved ejection fraction (HFpEF). BACKGROUND PH is commonly associated with HFpEF. The predictors of mortality for patients with these conditions are not well characterized. METHODS In a prospective cohort of patients with right heart catheterization, we identified 73 adult patients who had pulmonary hypertension due to left heart disease (PH-LHD) associated with HFpEF (left ventricular ejection fraction ≥50% by echocardiography); hemodynamically defined as a mean pulmonary artery pressure ≥25 mm Hg and pulmonary artery wedge pressure >15 mm Hg. PH severity was classified according to the diastolic pressure gradient (DPG). Cox proportional hazards ratios were used to estimate the associations between clinical variables and mortality. Receiver-operating characteristic curves were used to evaluate the ability of hemodynamic measurements to predict mortality. RESULTS The mean age for study subjects was 69 ± 12 years and 74% were female. Patients classified as having combined post-capillary PH and pre-capillary PH (DPG ≥7) were not at increased risk of death as compared to patients with isolated post-capillary PH (DPG <7). A baseline pulmonary arterial capacitance (PAC) of <1.1 ml/mm Hg was 91% sensitive in predicting mortality, with better discriminatory ability than DPG, transpulmonary gradient, or pulmonary vascular resistance (area under the curve of 0.73, 0.50, 0.45, and 0.37, respectively). Fifty-seven subjects underwent acute vasoreactivity testing with inhaled nitric oxide. Acute vasodilator response by the Rich or Sitbon criteria was not associated with improved survival. CONCLUSIONS PAC is the best predictor of mortality in our cohort and may be useful in describing phenotypic subgroups among those with PH-LHD associated with HFpEF. Acute vasodilator testing did not predict outcome in our cohort but needs to be further investigated.
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Affiliation(s)
| | - Ioana R Preston
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Jessica K Paulus
- Tufts Clinical and Translational Science Institute, Boston, Massachusetts
| | - Nicholas S Hill
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Kari E Roberts
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts.
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18
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Richter SE, Roberts KE, Preston IR, Hill NS. A Simple Derived Prediction Score for the Identification of an Elevated Pulmonary Artery Wedge Pressure Using Precatheterization Clinical Data in Patients Referred to a Pulmonary Hypertension Center. Chest 2016; 149:1261-8. [PMID: 26501213 DOI: 10.1378/chest.15-0819] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Revised: 09/13/2015] [Accepted: 10/05/2015] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND One of the foremost diagnostic challenges in clinical pulmonary hypertension is discriminating between pulmonary arterial hypertension (group 1) and heart failure with preserved ejection fraction (group 2.2). Group 2.2 is defined as a normal left ventricular ejection fraction (> 50%) and a pulmonary arterial wedge pressure (PAWP) > 15 mm Hg. We aimed to determine whether patient history, demographics, and noninvasive measures could predict PAWP before to right heart catheterization. METHODS Data were prospectively collected on 350 consecutive patients at a single tertiary care medical center; of these patients, 151 met criteria for entry into our study (88 in group 1 and 63 in group 2.2). Data included historical features, demographics, and results of a transthoracic echocardiogram. A multivariate regression model was developed to predict PAWP > 15 mm Hg. RESULTS Univariate predictors of PAWP > 15 mm Hg included older age, higher BMI and weight, systemic systolic BP and pulse pressure, more features of the metabolic syndrome, presence of hypertension and left atrial enlargement, absence of right ventricular enlargement, and lower glomerular filtration rate and 6-min walk distance. The optimal model for predicting PAWP > 15 mm Hg was composed of age (> 68 years), BMI (> 30 kg/m(2)), absence of right ventricular enlargement, and presence of left atrial enlargement (area under the curve, 0.779). CONCLUSIONS Clinical characteristics obtained before diagnostic right heart catheterization accurately predict the probability of elevation of PAWP > 15 mm Hg in patients with preserved ejection fraction. These combined clinical characteristics can be used a priori to predict the likelihood of group 2.2 pulmonary hypertension.
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Affiliation(s)
- Stefan E Richter
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, Los Angeles, Los Angeles, CA.
| | - Kari E Roberts
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, Boston, MA
| | - Ioana R Preston
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, Boston, MA
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, Boston, MA
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Abstract
Pulmonary hypertension is clinically defined by a mean pulmonary artery (PA) pressure of 25mm Hg or more at rest, as measured by right heart catheterization. To identify patients who are likely to have a beneficial response to calcium channel blockers (CCBs) and therefore a better prognosis, acute vasodilator testing should be performed in patients in certain subsets of pulmonary arterial hypertension (PAH). A near normalization of pulmonary hemodynamics is needed before patients can be considered for therapy with CCBs. Intravenous adenosine, intravenous epoprostenol, inhaled nitric oxide, or inhaled iloprost are the standard agents used for vasoreactivity testing in patients with idiopathic PAH. In this review we describe the various aspects of vasodilator testing including the rationale, pathophysiology and agents used in the procedure.
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20
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Jentzer JC, Mathier MA. Pulmonary Hypertension in the Intensive Care Unit. J Intensive Care Med 2015; 31:369-85. [PMID: 25944777 DOI: 10.1177/0885066615583652] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 03/16/2015] [Indexed: 12/19/2022]
Abstract
Pulmonary hypertension occurs as the result of disease processes increasing pressure within the pulmonary circulation, eventually leading to right ventricular failure. Patients may become critically ill from complications of pulmonary hypertension and right ventricular failure or may develop pulmonary hypertension as the result of critical illness. Diagnostic testing should evaluate for common causes such as left heart failure, hypoxemic lung disease and pulmonary embolism. Relatively few patients with pulmonary hypertension encountered in clinical practice require specific pharmacologic treatment of pulmonary hypertension targeting the pulmonary vasculature. Management of right ventricular failure involves optimization of preload, maintenance of systemic blood pressure and augmentation of inotropy to restore systemic perfusion. Selected patients may require pharmacologic therapy to reduce right ventricular afterload by directly targeting the pulmonary vasculature, but only after excluding elevated left heart filling pressures and confirming increased pulmonary vascular resistance. Critically-ill patients with pulmonary hypertension remain at high risk of adverse outcomes, requiring a diligent and thoughtful approach to diagnosis and treatment.
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Affiliation(s)
- Jacob C Jentzer
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, PA, USA Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael A Mathier
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, PA, USA
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21
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Muzevich KM, Chohan H, Grinnan DC. Management of pulmonary vasodilator therapy in patients with pulmonary arterial hypertension during critical illness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:523. [PMID: 25673176 PMCID: PMC4331447 DOI: 10.1186/s13054-014-0523-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Pulmonary arterial hypertension (PAH) is commonly treated with pulmonary arteriolar vasodilator therapy. When a patient on PAH medication is admitted to intensive care, determining how to manage their medication during the critical illness is often complicated. There may be considerations related to the inability to take medication by mouth, related to acute renal failure or acute liver injury, related to altered mental status or delirium, or related to hypotension and bacteremia. Decisions of how to manage these medications can have a major impact on the patient’s clinical course. Presently, provider experience is the major tool in navigating the decisions regarding these medications. In this review, we offer our recommendations of how to manage PAH patients with critical illness who are on PAH medications. These recommendations include how to deliver medications via feeding tubes, how to dose medications in the setting of acute renal failure or acute liver failure, and how to manage medications during hypotension or when a tunneled catheter needs to be removed.
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