Leg raise can detect exercise-induced pulmonary arterial wedge pressure elevation

Background

Exercise-induced elevation of pulmonary arterial wedge pressure (PAWP) may show preclinical or exercise-induced left ventricular diastolic dysfunction. Invasive hemodynamic assessment during provocative maneuvers, like exercise and volume challenge, in these patients allows greater sensitivity to diagnose or exclude HFpEF. The aim of this study was to examine how the leg raise, which is a simple way to increase preload, can detect exercise-induced PAWP elevation.

Methods

Four hundred seventy-nine patients (60±14y.o, mean pulmonary arterial pressure (PAP) 19mmHg, PAWP 8mmHg, CTEPH /IPAH/CTD-PH/SOB unknown reason: 357/56/38/28pts) with near-normal PAP and normal PAWP at rest underwent symptom-limited exercise test using supine cycle ergometer with right heart catheter. Exercise-induced elevation in PAWP of over 20mmHg was defined as exercise-induced elevation group.

Results

ΔPAWP (after leg raise - rest) in the exercise-induced elevation group was significantly higher (6.0±4.1 vs. 2.7±3.9mmHg, p<0.001, in the older (age≥60y.o) group (n=276); 3.4±3.5 vs. 1.9±3.4mmHg, p<0.001, in the younger (age<60y.o) group (n=203)) than that in the non-elevation group after legs raise for cycle ergometer exercise. The area under the ROC curve for ΔPAWP was 0.72 (95% CI: 0.65–0.78) in the older and 0.64 (95% CI: 0.53–0.75) in the younger. In the older, the cut-off value for detect exercise-induced PAWP elevation of ΔPAWP was 4mmHg, with 72% sensitivity and 58% specificity. On the other hand, in the younger, the cut-off value was 3mmHg, with 69% sensitivity and 59% specificity.

Conclusion

Leg raise can easily detect occult left ventricular diastolic dysfunction.

Funding Acknowledgement

Type of funding source: None

Comparison of pulmonary vascular resistance and pulmonary artery compliance during exercise between IPAH and CTEPH with normal pulmonary artery pressure

Background

Pulmonary vascular resistance (PVR) and pulmonary artery compliance (PAC) are inversely related. However, the little is known about dynamics during exercise by disease difference. The aim of this study was to reveal the relationships of PVR and PAC during exercise between idiopathic pulmonary arterial hypertension (IPAH) and chronic thromboembolic pulmonary hypertension (CTEPH) patients.

Methods

Sixty-two IPAH patients (45±9 y.o) and 359 CTEPH patients (63±13 y.o) with normal mean PAP and PAWP at rest underwent symptom-limited exercise test using supine cycle ergometer with right heart catheter.

Results

There were no differences between baseline mean PAP and PAWP in 2 groups, however, cardiac output, SaO2 and SvO2 were lower in CTEPH group. Lower PAC (2.9±1.1 vs. 3.7±1.7 ml/mmHg, p<0.001) and higher PVR (2.3±1.0 vs. 1.9±1.0 wood.unit, p=0.016) were observed in CTEPH group. These trends were also seen at peak exercise. PVR-PAC relationship in CTEPH group was leftward shift compared with IPAH group (Figure 1).

Conclusion

Resting and exercise PVR and PAC in CTEPH patients were worse than those in IPAH patients who had normal PAP and PAWP at rest.

Figure 1

Funding Acknowledgement

Type of funding source: None

Usefulness of peripheral-pressure-directed balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension

Background

Balloon pulmonary angioplasty (BPA) in expert center may be considered in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are technically non-operable for pulmonary endarterectomy. BPA based on objective quantitative methods has not been established. The endpoint at BPA sessions has not been clarified yet.

Objectives

The purpose of this study was to investigate the usefulness of BPA according to peripheral pressure measured by pressure wire or catheter.

Methods

This study included consecutive 143 CTEPH who underwent cardiopulmonary exercise test with right heart catheterization after BPA. All patients were divided into 2 groups such as angio-guided (n=47) group or pressure-guidedgroup (n=96). In pressure-guided group, the pulmonary arterial pressure (PAP) proximal and distal to the target lesion and the ratio of the 2 pressures were measured by the pressure wire or catheter. the endpoint was determined to when the pressure ratio of distal to proximal pressures was >0.7 to 0.8 finally. The dilation was stopped when the distal mean PAP after each dilation reached 35 mm Hg and when the baseline mean PAP was >35 mm Hg. Changes of hemodynamic parameters such as PAP and pulmonary vascular resistance (PVR) from baseline, and mean PAP and PVR at peak oxygen consumption, and pulmonary arterial pressure – cardiac output (PA-CO) slope were compared between two groups. All data except changes of hemodynamics from baseline were expressed by median [25th percentile-75th percentile]. Changes of hemodynamics from baseline were expressed by average [95% confidence interval]

Results

The median age and male were 66 [56–72] years old and 35. There were no significant differences in number of sessions and dilated vessels between two groups (Angio-guided group vs. Pressure-guided group: 4 [3–6] vs. 4 [3–5], P>0.05; 19 [12–22] vs. 17 [13–22], P>0.05). Changes of PAP and PVR from baseline in pressure-guided group was significantly higher than in angio-guided groups (Angio-guided group vs. Pressure-guided group; ΔPAP: −19 [−20 to −17] vs. −20 [−21 to −20], P>0.05; ΔPVR: −6.0 [−6.3 to −5.7] vs. −6.6 [−6.8 to −6.3], P<0.01). Mean PAP and PVR at peak oxygen consumption (VO2) and PA-CO slope in pressure-guided group were significantly lower than in angio-guided group (Angio-guided group vs. Pressure-guided group; PAP at VO2: 43 [36–50] vs. 39 [34–43], P<0.05; PVR at VO2: 2.7 [1.9–4.5] vs. 2.2 [1.6–2.9], P<0.01; PA-CO slope: 3.8 [2.1–5.2] vs. 2.9 [1.9–4.0], P<0.05).

Conclusions

Peripheral-pressure-directed BPA can improve hemodynamics at rest and exercise more effectively.

Funding Acknowledgement

Type of funding source: None

Incorporation of intraportally infused [15N]ammonia into urinary uric acid in cockerels pretreated with methionine sulfoximine

1. Measurements were made in situ to determine the incorporation of intraportally infused ammonia-15N into urinary uric acid in cockerels pre-treated with methionine sulfoximine (MSM), a glutamine synthetase inhibitor. 2. The incorporation of 15N into urinary uric acid was 34% of the infused amount in MSM-treated birds. This was not significantly different from the value of 46% for control birds. 3. Pre-treatment with MSM inhibited the activity of liver glutamine synthetase to 7% of the control value and decreased the incorporation of the infused ammonia-15N into plasma glutamine amide-N to 3% of the control. 4. Increases in glutamine concentrations in the blood, liver and kidney caused by the infusion of ammonia were also completely inhibited by the MSM treatment (P less than 0.05). 5. It is concluded that in the cockerel ammonia-N can be incorporated into uric acid other than by glutamine formation.

Effects of varying doses of methionine sulfoximine on liver glutamine synthetase activity and time courses of blood and urinary nitrogenous compounds in the chicken (Gallus domesticus)

1. The activity of liver glutamine synthetase was inhibited to 7-12% of the control activity by an intracardiac injection with methionine sulfoximine (MSM) at dosages of 20, 50, 75 and 100 mg/kg body wt. 2. Plasma glutamine concentrations in all the MSM treatments decreased sharply, then reached steady-state levels within 0.5-2.5 hr, which were almost proportional to a dose of MSM. 3. Blood ammonia concentration sharply increased to a steady-state level attained at 4.5 hr, which was proportional to a dose of MSM. The excretion rate of urinary ammonia augmented linearly up to the dose dependent maximum rates within 2-5 hr. 4. Plasma uric acid concentration dropped linearly by about 6.4 mg/100 ml at doses of 50, 75 and 100 mg MSM and by 3.7 mg/100 ml at a dose of 20 mg MSM within 2.5 hr, then recovered a little. 5. The decreases in excretion rates of urinary uric acid for the first 4 hr were almost the same at doses of 50 mg and larger, being twice as large as that of the control chicken. 6. Any doses of MSM affected neither the time course of excretion rate of total urinary nitrogen nor its total amounts for 7 hr after MSM treatment.

Ammonia absorption from different parts of chicken intestine and its quantitative evaluation in situ

Ammonia was more rapidly absorbed from the ileum than the jejunum, and the lower the small intestine was, the more rapid was the absorption of lumen fluid. About 95% of ammonia-15N introduced into the intestinal sac having Meckel's diverticulum in the middle part disappeared in 30 min, of which 90% was recovered as non-protein-N in the blood of the mesenteric vein draining the sac and in the mucosa of the tested portion in 30 min. About 57% of ammonia which disappeared from the intestinal lumen was found as ammonia-N and 26% as other non-protein-N in the mesenteric blood. Maximal rates of appearance of total non-protein-15N and ammonia-15N in the mesenteric blood were found within 10 min and returned to the levels at 0-5 min in 30 min.

[Inhibitory effects of methyl o-(4-hydroxy-3-methoxycinnamoyl) reserpate (CD-3400) on the central nervous system (author's transl)]

Effects of methyl o-(4-hydroxy-3-methoxycinnamoyl) reserpate (CD-3400) on the central nervous system in mice, rats and cats were investigated, and a comparison was made with such effects of reserpine and rescinamine. Inhibitory effects of CD-3400 on spontaneous motor activity and conditioned avoidance response were weaker and shorter than those of reserpine and rescinnamine. In the experiments of the inhibitory effects of the central actions such as ptosis, hypothermia, decrease in motor ability, potentiation of hexobarbital and taming, reserpine was found to be the most potent followed by rescinnamine and CD-3400, respectively. High doses of CD-3400 exhibited inhibitory effects on methamphetamine-induced hyperactivity in mice and this action was weaker than those of reserpine and rescinnamine. CD-3400, 80-160 mg/kg p.o., showed no significant effects on morphine-induced analgesia, while a slight inhibition was observed on the Straub-tail reaction using morphine. Reserpine, 0.5 mg/kg i.v., resulted in a drowsy pattern in the spontaneous EEG activity and the EEG arousal response was depressed, while with CD-3400, 5 mg/kg i.v., there was no drowsy pattern. CD-3400 as well as rescinnamine and reserpine remarkably depleted 5-HT levels in brain, heart and plasma and the potency of CD-3400, particularly in the brain, was weaker than the potency of reserpine and rescinnamine. These results indicate that CD-3400 is an antihypertensive agent with a low toxicity and a weak central action.