Is bilateral lung transplantation in pulmonary artery hypertension related to congenital heart disease a real therapeutic option? Experience of a national referral centre

Background

Pulmonary arterial hypertension (PAH) affects almost 10% of patients with congenital heart disease, markedly worsening their prognosis. Bilateral lung or cardiopulmonary transplantation is therefore the last therapeutic option. The presence of underlying congenital heart disease (CHD) leads many of these patients directly to cardiopulmonary transplantation. However, this option is increasingly limited due to the shortage of organs and the high risk of the procedure.

Purpose

Demonstrate that isolated bilateral lung transplantation (BLT) associated with repair of simple heart defects is an option that leads to good prognostic outcomes and adequate positive cardiac chamber remodelling.

Methods

We retrospectively analysed the cases of PAH-CHD in our centre who underwent BLT from September 2010 to January 2022.

Results

During the recorded time 12 of the 135 PAH-CHD patients followed in our unit were considered for transplantation. Six BLT were finally performed. The reasons for rejecting the option of transplantation in patients with congenital heart disease included, in addition to the usual ones (age, histocompatibility, comorbidities, ...) the presence of abundant collateral circulation or repeated thoracic interventions. Of the 6 patients who underwent transplantation of both lungs, the mean age was 39±10 years and 4 were women (66.6%). All of them had previous symptoms of heart failure, 4 of them presented recurrent supraventricular arrhythmias requiring ablation, one of them required stent implantation in the left coronary trunk due to extrinsic compression by the pulmonary artery trunk and another had presented threatening haemoptysis requiring embolization of bronchial branches. Regarding the aetiology of PAH-CHD, two of the patients had residual PAH after previous closure of the intracardiac defect years earlier and the remaining four patients (66.6%) had an incidental intracardiac shunt (2 ASD and 2 VSD). Both incidental ASD were closed in the main intervention. The course of the operation and immediate post-transplantation was similar to other PAH transplants, with a mean ICU stay of 10 days. All patients were discharged home and remain alive to date without recurrence of cardiovascular symptoms. On post-transplant echocardiographic re-evaluation, all patients had normalized right chambers in terms of both size and function (Table 1).

Conclusion

Isolated bilateral lung transplantation is a real option for most cases of pulmonary arterial hypertension associated with congenital heart disease with simple or previously repaired defects. BLT in these patients is not accompanied by a higher rate of complications in the immediate postoperative period and in the long term means the resolution of cardiovascular symptoms with the adequate positive remodelling of the right chambers.

Funding Acknowledgement

Type of funding sources: None.

The patient with Down syndrome and pulmonary arterial hypertension associated with congenital heart disease: from childhood to adulthood

 

Pulmonary arterial hypertension (PAH) is a common complication of congenital heart disease (CHD) that significantly affects its prognosis. Down syndrome is a common comorbidity among patients with PAH associated with CHD. Children born in recent years with CHD have benefited from advances in pediatric cardiac surgery that have modified their evolution compared to adults with the same pathologies. Our objective was to know and compare the characteristics of the adult and pediatric population with DS and PAH associated with CHD.

REHAP and REHIPED are Spanish, voluntary, multicenter registries that include patients with PAH associated with CHD. REHAP started in 2007 and includes patients over 18 years of age. Patients diagnosed with PAH after this time were prospectively included, until 2021. Patients who were followed in the participating centers and diagnosed after January 1998 were retrospectively included in the registry. REHIPED started in 2009 and collects patients between 2 months and 18 years of age. Patients diagnosed with PAH after this time were prospectively included, until 2021. Patients who were followed and diagnosed after January 1998 were retrospectively included. 131 adults and 47 children with DS and PAH associated with CHD were analyzed. Their baseline characteristics, hemodynamics, treatment, and 10-year survival were compared.

Adult patients with DS presented more frequently complete atrioventricular canal defect as underlying heart disease and were mostly in Eisenmenger's situation (84%). In pediatric patients the largest group was post-repair PAH (50%). Functional class was similar in both groups, although adults presented significantly greater hemodynamic severity. Regarding medical treatment, no differences were observed between both groups: there was a very low use of prostanoids both at baseline and at follow-up, and a majority use of oral monotherapy. There were no significant differences in survival.

Corrective surgery in patients with DS has become more frequent over the years: adults are mostly in Eisenmenger's situation, while post-repair PAH is the most numerous group in children. Although adults show greater hemodynamic severity, survival is similar in both groups. Medical treatment, which showed no differences between pediatric and adult age, is very conservative, with most patients on oral monotherapy and rare use of prostanoids.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Janssen MSD

Hemodynamic pulmonary response to exercise according to different resting pulmonary hypertension thresholds in chronic thromboembolic pulmonary disease

Background

Chronic thromboembolic pulmonary disease (CTEPD) defines all symptomatic patients who present mismatched perfusion defects on ventilation/perfusion (V/Q) scan and specific signs of organized fibrotic clots on computed tomography after at least three months of adequate anticoagulation in the absence of pulmonary hypertension (PH) at rest. Exercise limitation in CTED has been attributed either to an abnormal hemodynamic response to exercise or increased dead space ventilation. The proposal to decrease the PH threshold to mean pulmonary arterial pressure (mPAP) ≥20 mmHg and pulmonary vascular resistance (PVR) >3 uWood (uW) in all PH groups could identify a subgroup of patients with borderline PH criteria, and an abnormal response at exercise in CTEPD.

Aim

We sought to determine the hemodynamic behaviour at exercise according to different resting pulmonary pressures in a cohort of patients with CTEPD.

Methods

We selected symptomatic patients with confirmed perfusion defects in lung scintigraphy despite optimal anticoagulant therapy for a minimum of 6 months after a pulmonary embolism.Significant PH were ruled out with right heart catheterization (RHC): inclusion criteria implied mPAP <25 mmHg and PVR <3 uW and pulmonary arterial wedge pressure (PWAP) <15 mmHg. Exercise RHC was performed in supine following an incremental stepwise protocol using a cycle ergometer. Pulmonary pressures and cardiac output (CO) estimated by thermodilution were collected in each exercise level. Abnormal hemodynamic exercise response was defined when a value of multipoint mPAP/CO slope >3 mmHg L–1 min–1 was reached. Patients were stratified in three groups according to resting mPAP and PVR: 1) Normal-no PH (mPAP <20 mmH + RVP <2 uW), 2) Borderline (mPAP ≥20 + RVP <3 uW), 3) mild PH (mPAP ≥20 mmHg + RVP >3 uW).

Results

Twenty-two CTEPD patients were stratified into three groups 1) mild PH: 3 patients, 2) borderline PH: 11 patients and 3) no PH: 8 patients. Median age between groups did not reveal differences. At rest, the mild PH group showed higher mPAP, higher total pulmonary resistance (TPR) and lower compliance, relative to borderline and normal groups without significant differences in PWAP and stroke volume (Figure 1). At peak exercise, no differences in the estimated flow between the three groups were found, despite a substantial increase of mPAP with respect to resting pressures (57.3±11 mmHg Vs 47.7±10.0 mmHg vs 34.1±5.7 mmHg, p trend = 0.006). The prevalence of an abnormal hemodynamic response the mild, borderline and normal groups was 100%, 63.6% and 37.5% respectively. Figure 2 summarizes exercise RHC parameters.

Conclusion

In patients with CTEPD, the presence of borderline or mild PH at rest, predicts an abnormal hemodynamic response to exercise, when compared with patients with no PH at rest. Nevertheless, in this latter group, more than a third of patients showed an abnormal response, suggesting the presence of established pulmonary vasculopathy

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Sociedad Española de Cardiologia

Ventilatory inefficiency predicts abnormal hemodynamic response to exercise in chronic thromboembolic disease

Background

Chronic thromboembolic disease (CTED) refers to the presence of chronic thrombotic pulmonary vascular occlusion in the absence of pulmonary hypertension (PH) at rest. Nevertheless, their exercise tolerance may be decreased. We hypothesized that exercise intolerance may be explained by an abnormal haemodynamic response to exercise and that this may correlate to the functional and ventilatory parameters exhibited at the cardiopulmonary exercise test (CPET).

Objective

To evaluate the values reached in the CPET according to the hemodynamic response to exercise at the exercise right heart catheterization (RHC) in patients with CTED.

Methods

We selected symptomatic patients with confirmed perfusion defects in lung scintigraphy despite optimal anticoagulant therapy for a minimum of 6 months after a pulmonary embolism with normal lung function tests. Thrombotic burden was assessed with computed tomography (CT). Left heart disease (LHD) and PH were ruled out with RHC (inclusion criteria implied mean pulmonary arterial pressure (mPAP)<25 mmHg and pulmonary vascular resistance (PVR)<3 uW and pulmonary arterial wedge pressure (PAWP)<15 mmHg). All patients underwent a cardiopulmonary exercise test (CPET). Exercise RHC was performed within 24 hours after CPET. The exercise protocol was the same for both tests. Pulmonary pressures and cardiac output (CO) were collected at each exercise level. Abnormal hemodynamic exercise response was considered following the proposal of the 2020 CTED consensus (mPAP/CO slope >3 mmHg/L/min).

Results

22 patients (median age 54.5±14.8 years, 32% females) were included, of whom 13 (59%) showed an abnormal hemodynamic response (mPAP/CO slope 4.5 vs 2.3 mmHg/L/min, Figure 1A). Baseline characteristics and time from the embolic event were similar in both groups (3.4 vs 2.5 years, p=0.815) (Table 1). Patients with abnormal exercise response showed worse ventilatory efficiency at the CPET: 1) a flattened end-tidal carbon dioxide pressure pattern (PetCO2) (Figure 1B), 2) a steeper VE/CO2 slope, and 3) a higher ventilatory equivalent for CO2 at the anaerobic threshold (EQCO2_AT); compared to the group with normal hemodynamic behavior. Oxygen consumption at the anaerobic threshold (VO2_AT) and peak oxygen consumption (VO2) were slightly decreased without statistically significant differences between groups. VE/CO2 slope, EqCO2_AT and PETCO2_AT showed a moderate mPAP/CO slope correlation (r=0.66, p<0.001; r=0.63, p=0.003; r=−0.51, p=0.017 respectively). PetCO2_AT and EqCO2_AT accurately discriminated between both groups with an area under the receiver operating characteristic curve of 0.752 and 0.710 respectively.

Conclusion

In patients with CTED and normal/near normal pulmonary pressures at rest, ventilatory inefficiency parameters in CPET correlate with an abnormal hemodynamic exercise response. PETCO2 pattern and EqCO2_AT accurately discriminated the subgroup with abnormal hemodynamic behaviour.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Sociedad Española de Cardiologia

BMPR2 variants in pulmonary arterial hypertension. Are they really worrisome?

Background

Pulmonary arterial hypertension (PAH) is a rare and severe disease. The discovery of the gene encoding Bone Morphogenetic Protein Receptor Type 2 (BMPR2) in 2000 was the first evidence of an association between genetics and PAH. BMPR2 mutation carriers are younger and have higher haemodynamic severity, determining higher risk than sporadic cases. In the last few years, novel genetic variants have been identified. The risk of mortality of the currently known mutations is scarce.

Purpose

To describe the role of gene variants regarding long-term survival in a cohort of PAH patients.

Methods

We included patients diagnosed with PAH between January 2011-December 2020, following the ESC/ERC Guidelines recommendations. At least one genetic study was available in included individuals. Pulmonary venooclusive disease, PAH associated with congenital heart disease, or connective tissue disorders were excluded. Three groups were compared: no mutation, BMPR2 carriers and other genetic variants. Comparison of qualitative and quantitative variables was done by Chi-square test and ANOVA test, respectively. Crude and adjusted Log-rank test was performed for the evaluation of mortality.

Results

361 were finally included. The most frequent gene variant was BMPR2. Among the eight other gene variants, there were 2 cases of KCKN3, 2 of ACVRL1, and 1 case of KCNA5, TBX4, CPS1, and GDF2.

BMPR2 and the rest of mutation carriers were younger at diagnosis and had worse haemodynamic parameters than non-carriers. Nevertheless, these patients tended to perform higher distances in the 6-minute walk test. Interestingly, BMPR2 patients had higher DLCO values at diagnosis (table).

After 104.1±77.2 months of follow-up, there was a tendency for BMPR2 carriers toward lower crude free survival of mortality or lung transplantation. Nevertheless, this survival benefit disappears when adjusted by age (Table, figure).

Conclusions

The diagnostic yields of genetic analysis for pathogenic or likely pathogenic variants in idiopathic PAH are approximately 11%. BMPR2 is the most frequent causal gene. These patients are associated with marked haemodynamic impairment. Nevertheless, its younger age probably determines the better long-term results regarding mortality or lung transplantation observed when comparing these results with sporadic patients or those carrying other mutations.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Rio Hortega grant. Instituto de Salud Carlos III (ISCIII), Ministry of Science and Innovation, Spanish Government.

Pulmonary arterial hypertension associated with congenital heart disease in children and adults: knowing the present to imagine the future

Introduction

Pulmonary arterial hypertension (PAH) is a common comorbidity in congenital heart disease (CHD) and significantly affects prognosis. Children born in recent years with CHD have benefited from advances in pediatric cardiac surgery that have modified their evolution compared to adults with the same pathologies.

Purpose

Our objective was to define and compare the characteristics of the adult and pediatric population with PAH associated with CHD.

Methods

REHAP and REHIPED are Spanish, voluntary, multicenter registries that include patients with PAH associated with CHD. REHAP started in 2007 and includes patients over 18 years of age. Patients diagnosed with PAH after this time were prospectively included, until 2020. Patients who were followed in the participating centres and diagnosed after January 1998 were retrospectively included in the registry. REHIPED started in 2009 and collects patients between 2 months and 18 years of age. Patients diagnosed with PAH after this time were prospectively included, until 2020. Patients who were followed and diagnosed after January 1998 were retrospectively included. The baseline characteristics, hemodynamic profile, treatment, and 10-year survival of the REHAP patients were compared to those included in the REHIPED. In addition, the change in the distribution of etiologies of REHAP over time was analyzed.

Results

664 patients were included from REHAP (mean age 32±20 years) and 153 from REHIPED (mean age 5±5 years). Among adults, there was a significantly higher proportion of women (67% versus 56%, p 0.004), patients with Eisenmenger syndrome and simple heart disease. The frequency of the different clinical groups has varied over the years, becoming progressively similar to the distribution observed in REHIPED. Adults presented greater hemodynamic severity, with higher mean pulmonary arterial pressure and greater pulmonary vascular resistance index. There were no differences in initial therapy or in the percentage of patients who received prostanoids at follow-up. Survival at 10 years was better in the group of children (99% at 1 year, 95% at 5 and 80% at 10) than in the adult group (94% at 1 year, 83% at 5 and 71% at 10) with a HR of 1.93 [95% CI 1.2–3] for REHAP compared to REHIPED.

Conclusions

Patients with PAH associated with CHD have different clinical and prognostic characteristics in childhood and adulthood. Knowing the characteristic of the pediatric age can help predict how the future patients with PAH associated with CHD will be and how we can plan their care.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Ferrer, MSD, Janssen, GSK Table 1Figure 1

Usefulness of transthoracic echocardiography for pulmonary artery aneurysm screening in patients with pulmonary arterial hypertension

Background/Introduction

Pulmonary artery aneurysm (PAA), defined as a pulmonary artery (PA) diameter >40 mm, is a common finding among pulmonary arterial hypertension (PAH) patients. Although often asymptomatic, PAA may lead to life-threatening complications such as left main coronary artery compression or PA dissection. Transthoracic echocardiography (TTE) is regularly employed for risk assessment in PAH patients. However, TTE accuracy for PA measurement has not been evaluated, and current practice guidelines lack formal recommendations for PAA screening and follow-up. We aim to determine whether TTE is an appropriate tool for PA diameter measurement and determine an optimal cut-off point to diagnose a PAA through TTE.

Methods

We retrospectively analyzed a cohort of 657 PAH patients followed up at a national referral centre. For this analysis, we selected those patients who had undergone at least one TTE and one computed tomography (CT) or magnetic resonance (MR) within six months before or after the TTE. We performed an agreement analysis between CT/MR-based and TTE-based PA diameter using the Passing–Bablok method. Furthermore, we calculated the area under the curve for the identification of a PAA with a TTE (compared to CT/MR).

Results

We analyzed 281 simultaneous CT/MR and TTE of a total of 178 PAH patients (71% women). Median age at diagnosis was 42.1 (32.2–58.0) years. PAH etiology was idiopathic or familial in 67 (38%), associated with congenital heart disease in 28 (16%) and associated with connective tissue disease in 36 (20%) patients. In 46 (26%) patients PAH was associated with other entities, such as human immunodeficiency virus, pulmonary veno-occlusive disease, drugs or portal hypertension. We found a significant correlation between PA diameter measured in TTE and CT/CMR (Lin's concordance correlation coefficient = 0.851) (Figure 1). The area under the curve for the detection of PAA was 0.91 (95% CI 0.88–0.95, p=0.018) (Figure 2). We selected a TTE-based PA diameter 37 mm as the optimal cut-off point for PAA identification. This diameter correctly classified 85.4% of measurements with a sensitivity and a specificity of 83.2% and 87.2%, respectively.

Conclusion

Our study demonstrates that TTE is an adequate tool for PA diameter quantification with a strong correlation with CT/MR. This good correlation makes TTE an excellent tool for PAA screening among PAH patients, avoiding unnecessary CT or MR scan and helping to identify those patients in whom close follow-up is advisable. Based on these results, we recommend the inclusion of PA diameter measurement in TTE acquisition protocols for PAH patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Passing–Bablok regression lineFigure 2. ROC curve for PAA detection with TTE

The results of the balloon pulmonary angioplasty program in chronic thromboembolic pulmonary hypertension patients in a national and European reference center resemble those of Japanese series

Introduction

Balloon pulmonary angioplasty (BPA) is an established technique in patients with non-operable chronic thromboembolic pulmonary hypertension (CTEPH). It improves hemodynamics, functional class, biomarkers and survival, with current periprocedural mortality rates below 1–2% in experienced centers. However, there is a discrepancy between the magnitude of European or American series' results and those of Japanese centers, with a pulmonary vascular resistance reduction of 26–43% in the former and 45–65% in the latter.

Purpose

To present the results of the BPA program of a CTEPH national and European reference center and to compare them with the results of Japanese series.

Methods

We analyze the improvement in hemodynamics, functional parameters, biomarkers and pulmonary vasodilators requirements of patients with a finished BPA program. Besides, we show safety and survival of the whole cohort of patients undergoing BPA between May 2013 and December 2020 in a CTEPH national and European reference center.

Results

We performed 503 BPA sessions in 120 patients, 64% women, mean age 61±15 years (19–84). The reasons for BPA were: distal involvement in 105 patients, comorbidities in 3 patients, personal preferences in 3 patients and residual pulmonary hypertension after pulmonary thromboendarterectomy in 9 patients. Mean follow-up from therapy beginning was 50±16 months (22–92). One patient died 7 days after her first BPA due to severe lung injury (peri-procedural mortality 0.83%). BPA therapy was interrupted in 5 patients (4 octogenarians with poor tolerance to procedures or little clinical improvement and 1 patient with relapsing severe hemoptysis during BPA sessions). Seventy three of the 114 remaining patients had finished their BPA program. The table shows the hemodynamic, biomarker and functional class improvement and the decrease in pulmonary vasodilators requirements of patients with complete BPA therapy. During follow-up 2 patients died: one due to hemoptysis related to pneumonia, 23 months after his first BPA, with BPA program already completed; the other due to leukemia, while in active BPA program. Thus, survival of our BPA series at 7 years follow-up is 98.2%.

Conclusions

The efficacy, safety and survival results of BPA therapy in patients with inoperable CTEPH at a national and European reference CTEPH center are comparable to those of Japanese series. Furthermore, hemodynamic and functional improvement and the reduction of specific medication requirements, along with therapy safety, position BPA as the first choice therapeutic option in patients not subsidiary of surgery.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): University Hospital 12 de Octubre, Madrid, Spain Changes after complete BPA therapySurvival from the initial BPA procedure

Genetic background in pediatric pulmonary arterial hypertension. Should we change the current recommendations for genetic testing?

Background

Pulmonary arterial hypertension (PAH) is a rare and severe disease, genetically predisposed in a high proportion of patients. PAH is subclassified in different subtypes depending on the underlying condition. Gene variants are more frequent among heritable or idiopathic forms. Nevertheless, pathogenic variants have been described across the entire spectrum of this disease. Evidence regarding genetics in pediatric PAH is scarce [1].

Purpose

Our aim is to describe the prevalence of significant gene mutations among a pediatric PAH cohort and to define specific data in the different subtypes.

Methods

Samples for genetic studies were obtained from blood tests of patients included in the Spanish National Registry of Pediatric Pulmonary Hypertension (REHIPED). Guardians signed informed consent before the inclusion in the study. Qualitative variables were compared by Chi-square test. Quantitative variables were assessed by Kruskal-Wallis, considering the asymmetric distribution of variables. STATA 14.0 was used for analyses.

Results

Sixty four patients were included between 2011 and 2021. Median age of the entire sample was 7.1 years (2.0–12.6) and 42.2% of them were male. There were significant differences in the age at diagnosis and race between the different included groups (table). Pathogenic or likely pathogenic variants were more frequent in familial pulmonary venooclusive disease (PVOD) and familial PAH cases. A similar percentage of mutations were found in idiopathic cases and in PAH associated with congenital heart disease (Figure). Gene variants in the gene encoding the bone morphogenetic protein receptor type 2 (BMPR2) were the most frequent mutations in the PAH familial cohort and there was also the most frequent finding in congenital heart disease and sporadic PAH, in conjunction with the TBX4 gene. Homozygous or compound heterozygous EIF2AK4 (eukaryotic translation initiation factor 2 a kinase 4) mutations were found in all the patients diagnosed with PVOD. Heritable PAH and PVOD cases were diagnosed more frequently after family screening.

Conclusions

This study shows a comparable proportion of pathogenic-likely pathogenic gene mutations in patients diagnosed of pulmonary arterial hypertension associated with congenital heart disease and idiopathic cases, with similar distribution of specific genes. BMPR2 and TBX 4 were the most frequent gene variants in this pediatric PAH population. BMPR2 and EIF2AK4 are the most common mutations in familial PAH and PVOD subtypes, respectively.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ACU holds a Rio Hortega Grant from the Instituto de Salud Carlos III, Spanish Ministry of Science and Innovation.JAT and NG hold grants from FEDER (Federaciόn Española de Enfermedades Raras) and from the FCHP. Table 1. Characteristics of PAH subtypesFigure 1. PAH and ACMG classification.

Pulmonary arterial hypertension in Spanish pediatric registry age: clinical characterization, management and survival

Background

Pulmonary arterial hypertension (PAH) includes idiopathic PAH and congenital heart disease (CHD) related PAH. A wide variety of CHD can develop PAH, but their clinical characteristics define four large groups: Eisenmenger, PAH associated with non-restrictive shunt, severe PAH associated with restrictive shunt and postoperative PAH. Our aim was to study the clinical and prognostic differences between these groups and idiopathic PAH.

Methods

The REHIPED registry is a Spanish, multicenter, observational and prospective registry on pulmonary hypertension in the pediatric population (<18 years of age) that began in 2008. 183 patients were analyzed: baseline characteristics, functional class, right catheterization data, treatment and survival were compared

Results

183 patients were analyzed, characteristics are detailed in the table. In patients with idiopathic PAH, treatment with prostanoids was more frequently used as first line therapy and during follow up. The average follow-up time was 9 years. There was not a statistically significant difference in survival among the 4 clinical groups of CHD related PAH. There was a borderline significant difference (logrank p 0.05) in survival between the group of CHD related PAH and idiopathic PAH.

Conclusion

Idiopathic PAH patients have worse outcome than CHD related PAH patients although they have less comorbidities, less severe hemodynamics and are treated more aggressively.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Janssen, Ferrer

Are there real differences between the treatment for young and elderly patients with chronic thromboembolic pulmonary hypertension?

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially curable type of pulmonary hypertension, but it is poorly characterized in elderly patients.

Purpose

This study aimed to investigate the clinical characteristics, treatment strategy and survival of elderly patients with CTEPH.

Methods

All CTEPH patients evaluated at our institution between 2000 and 2018 were collected. They were divided into two groups according to 75th percentile of age. Thrombotic lesions were considered proximal when affecting the main pulmonary artery, lobular and proximal segmental arteries. All patients were discussed at a multidisciplinary team meeting. Pulmonary thromboendarterectomy (PTE) was the treatment of choice. Balloon pulmonary angioplasty (BPA) and vasodilator treatment were second-line strategies for those considered inoperable in view of unfavourable pulmonary vascular anatomy or comorbidities. As BPA program was started in our centre in 2013.

Results

484 patients were included. Baseline distinctive features are described in table 1. Medical therapy alone was more frequently considered in elderly patients. However, when adjusted for thrombotic lesions location, there were no differences in treatment strategies (p<0.0005). Mortality was higher in the elderly patients group (p<0.00005), with differences in cumulative survival distribution (p<0.00005). This differences was maintained even after adjusted analysis for thrombotic lesions location (p=0.01) (picture 1).

Conclusion

CTEPH in elderly patients shows more incidence of distal involvement, which limits the number of patients suitable for PTE. After adjusted for the location of the injuries, treatment strategies were similar between both groups. Nevertheless, mortality is still higher in elderly patients.

Picture 1

Funding Acknowledgement

Type of funding source: None

Pulmonary hypertension and pregnancy. Is it time to reconsider recommendations in certain groups? Contemporary outcomes in a tertiary referral centre

Background and aims

Pregnancy is as a major risk scenario for pulmonary hypertension (PH) females. Disease targeted therapy (DTT) has dramatically changed prognosis in certain PH groups, namely: pulmonary arterial hypertension (PAH), chronic thromboembolic PH (CTEPH) or segmental-PH; also facilitating pregnancy management. In spite a more benign course in the responders to calcium channel blockers subgroup (R-CCB), maternal mortality is thought to remain high and current recommendations still consider all PH-patients as very high risk (mWHO IV). We aimed to analyse pregnancy outcomes in PAH, CTEPH and segmental-PH in a contemporary cohort and to specifically assess pregnancy risks in the R-CCB subgroup.

Methods and results

All pregnant PAH, CTEPH and segmental PH patients and patients transferred within 8 weeks post-delivery between January 2000 and January 2020 to our centre were studied.

28 pregnancies were included. Mean age 28±6 years. Underlying aetiology: 10 (36%) Idiopathic-PAH, 4 (14%) Heritable-PAH (1 of them veno-occlussive disease-POVD-), 2 (7.1%)PAH-connective tissue disease, 9 (32,1%) PAH-congenital heart disease (1 Eisenmenger), 1 (3.6%) CPETH, 2 (7.1%) segmental-HP. 21% were R-CCB.

From the overall 28 pregnancies, 32% underwent early termination of pregnancy (ETP). When pregnancy was continued in non-responders, 5 (23%) were admitted from cardiac causes and up to 13% required inotropes. 66.7% of non-responders patients needed uptitration of PH-DTT along pregnancy (19% being discharged on prostacyclins). Considering the whole cohort, two patients (7.1%) died along the pregnancy period, both non-responders PAH (1 IPAH and 1 POVD). One died at ETP and the other one 48 hours after C-section at week 22. No R-CCB presented with maternal complications, and all continued on CCB without needing any change on treatment.

Regarding the new-born, average gestational age was 28 weeks and 53% suffered from some neonatal morbidity (only 1 R-CCB), including 1 neonatal death.

From a haemodynamic perspective, baseline mean pulmonary artery pressure (mPAP) was 41.9±15 mmHg, pulmonary vascular resistances (PVR) were at 7.1±4 WU. If haemodynamics were also available after pregnancy (53%), no significant increase in PVR was noted, although the required DTT was remarkably higher.

Survival-free of death or lung transplantation (Figure 1) was calculated at 78.57% over a median long-term follow-up of 6 years.

Conclusions

DTT has improved outcomes in pregnant PH females. Although mortality related to pregnancy appears high but not prohibited, maternal and neonatal morbidity is still very high. Moreover, ETP in this population is not without complications. In addition, DTT often requires uptitration suggesting disease progression. Nevertheless, R-CCB females appear to be able to complete pregnancy without events supporting our suggestion to reconsider their estimated pregnancy-associated risks.

Figure 1. 5-year survival

Funding Acknowledgement

Type of funding source: None

Cardiopulmonary exercise test could predict residual pulmonary hypertension after pulmonary endarterectomy

Introduction

Pathophysiology of chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by thrombotic lesions at pulmonary arteries and arteriolar remodeling in distal regions. There is an increase in pulmonary vascular resistance that will lead to heart failure and early death without treatment. Currently, pulmonary endarterectomy (PE) is the potentially curative treatment for this condition. Cardiopulmonary exercise test (CPET) allows to quantify functional improvement after PE. Objective: To analyze changes in CPET and hemodynamic parameters after surgery in a cohort of patients with CTEPH.

Methods

502 patients with CTEPH have been evaluated until December 2018, PE was performed in 255 (51%). In 49 patients, CPET was available before and 6 months after surgery. Residual pulmonary hypertension (RPH) was defined as mean pulmonary arterial pressure ≥30 mmHg evaluated by right cardiac catheterization at 3–6 months after PE.

Results

54% were men, mean age 48±13 years. Two thirds of patients were in functional class II/III at time of diagnosis and with severe hemodynamic and functional profile. Hemodynamics and CPET parameters improved after surgery. However, in patients with RPH they did not improve significantly. Results are shown in table.

Conclusions

PE restores functional capacity in CTEPH, represented by significant improvement in CPET parameters. CPET is emerging as a non-invasive technique suitable of detecting RPH. More studies are needed to confirm this hypothesis.

Funding Acknowledgement

Type of funding source: None

Pretriscuspid shunt and Eisenmenger syndrome: a deadly combination

Introduction

Pulmonary arterial hypertension (PAH) is a common comorbidity in congenital heart disease (CHD) and significantly affects prognosis. Our aim was to investigate how the location of the shunt influences the outcome of these patients.

Methods

The REHAP registry is a Spanish multicentre voluntary registry of patients over 14 years of age, which includes patients with congenital heart disease and PAH, starting in 2007. Baseline characteristics, functional class, right catheterization data, treatment and survival were compared. We performed a cox regression model for assessing the impact of the type of shunt on prognosis, after looking for confusing and effect modifying variables.

Results

664 patients were analyzed, their characteristics are detailed in the table. Mean follow up time was 10 years. We performed a survival analysis adjusted for the confounding variables: age (Hazard ratio (HR) 1.02 p<0.001), functional class (HR 2.45 p 0.001) and clinical group. The clinical group was also an effect-modifying variable, which means there is no unique effect (HR) of the type of shunt, instead it depends on the clinical group. We did a multiple regression analysis, adjusting for the confounding variables, to calculate the HR for each clinical group: in patients with Eisenmenger syndrome, the HR is 0.27 (p<0.001) for simple posttricuspid shunt and HR 0.38 (p<0.001) for complex posttricuspid shunt (reference group: pretricuspid shunt). In the others clinical groups, the type of shunt did not reach statistical significance.

Conclusion

The type of shunt significantly affects prognosis in Eisenmenger patients, with a much worse outcome for those with pretricuspid shunts. Functional class and clinical group are also closely related to outcome.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): MSD, GSK

Pulmonary hypertension and congenital heart disease: medical treatment and risk factors for survival

Background

Pulmonary arterial hypertension (PAH) is a common comorbidity in congenital heart disease (CHD) and significantly affects prognosis. There are four large clinical groups of CHD-related PAH: Eisenmenger syndrome, PAH associated with non-restrictive shunt, PAH associated with restrictive shunt and postoperative PAH. Our purpose was to study the clinical and prognostic differences among them.

Methods

The REHAP is a Spanish multicentre voluntary registry of patients over 14 years of age, which includes patients with CHD and PAH, starting in 2007. 664 patients were analyzed: Baseline characteristics, functional class, right catheterization data, treatment and survival were compared.

Results

664 patients were analyzed: characteristics are detailed in the table. Patients with Eisenmenger were more frequently treated with oral monotherapy as a first line therapy and received less frequently prostanoids during the follow-up. Patients with Eisenmenger had significantly better prognosis, with the best long-term survival of the 4 groups. In a cox regression model, postoperative PAH has a 1.7 hazard ratio (HR) (reference group: Eisenmenger) after adjustment for age (HR 1.02 p 0,001), functional class (HR NYHA III-IV 2.3 p<0,001), sex (p 0.8) and pulmonary vascular resistance (p 0.7).

Conclusion

The clinical classification of PAH associated with CHD defines both the baseline characteristics and the prognosis of patients. Outcome relates closely to functional class and type of PAH–CHD. Eisenmenger group, which has the most severe hemodynamics, is the one with the best prognosis despite a less aggressive treatment.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Ferrer, Janssen

Idiopathic pulmonary hypertension in Spanish pediatric registry: clinical characterization, management, and risk factors for survival

Introduction

Pulmonary arterial hypertension (PAH) is a rare disease that affects the small pulmonary arteries, producing gradual obliteration of arterial lumen leading to the progressive increase in pulmonary vascular resistance and, ultimately, right ventricular failure and death. Idiopathic PH refers to patients without an identifiable underlying cause, although some of them may have a genetic cause. Our aim was to define the baseline characteristics, initial therapy and risk factors for survival of patients with idiopathic PAH.

Methods

The REHIPED registry is a Spanish, multicenter, observational and prospective registry on pulmonary hypertension in the pediatric population (<18 years of age) that began in 2007. 47 patients with idiopathic PAH were analyzed.

Results

The mean age at diagnosis was 4.5 years, and there was a similar proportion of both sexes. 64% of patients were in functional class I-II. The mean pulmonary arterial pressure was 47,3±16,3 mmHg, with mean pulmonary vascular resistance index of 12±8,3 WU·m2. Initial therapy was oral monotherapy in 67%, prostanoids monotherapy in 11% and combination therapy with prostanoids in 9%. At the end of follow up, 55% of patients had received prostanoids. The mean follow-up time was 8 years. The survival rates (free of death or transplantation) was 91% (95% confidence interval (CI): 79–97%), 82% (95% CI: 67–91%) and 70% (95% CI: 52–82%) at 1, 5 and 10 years. Lung transplantation was performed in 7 patients. The main factors influencing survival, after adjustment for pulmonary vascular resistance, were functional class III-IV (Hazard Ratio (HR) 4.6, p=0.022, 95% CI: 1.3–15.3) and diagnosis under the age of 2 (HR 4, p=0.031, 95% CI: 1.1–14.4).

Conclusions

Idiopathic Pulmonary hypertension in pediatric age affects both sexes equally and begins at a young age. Prostanoids were used in 55% of patients. The main factors influencing survival, after adjustment for pulmonary vascular resistance, were functional class III-IV and diagnosis under the age of 2.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Janssen, Ferrer

P3675Prognostic implications of early detection and treatment of left main coronary artery compression by a pulmonary artery among pulmonary arterial hypertension patients

Introduction

Pulmonary artery aneurysm (PAA) is a common condition among pulmonary arterial hypertension (PAH) patients (38%). A pulmonary artery diameter ≥48 mm is an independent risk factor for sudden cardiac death in PAH patients. In the past years, the diagnosis of potentially lethal complications related to PAA is increasing. These complications include pulmonary artery dissection, bronchial compression and left main coronary artery compression (LMCAC). Our aim is to compare the survival and cause of death between PAA patients with a diagnosed and treated LMCAC and the rest of our PAA population.

Methods

Among our PAH population, we selected those patients who had a PAA diagnosis, defined as main pulmonary artery dilatation >40 mm. All the information was gathered from our institutional database. Patients with a suspected LMCAC based on computed tomography findings were evaluated with coronary angiography and treated surgically or percutaneously when LMCAC was confirmed. Survival from PAH diagnosis was estimated by the Kaplan–Meier method and compared by log-rank test between groups.

Results

86 patients in our cohort were diagnosed with a PAA (24% male, 49.8±12.5 years). In 10 (12%) patients, a LMCAC was diagnosed, 9 of them were treated with a percutaneous coronary intervention and the remaining one underwent PAA resection surgery due to severe pulmonary regurgitation. Among patients with LMCAC, only 3 presented chest pain and 2 had signs of ischemia in cardiopulmonary stress testing. In the other 5 patients, LMCAC was suspected after performing a thoracic computed tomography for different reasons: chronic cough in 1 patient, congenital heart disease evaluation in 2 patients and asymptomatic PAA follow-up in 2 patients. None of the patients presented complications secondary to revascularization. There were no differences between patients with and without LMCAC neither in age (49.5±12.9 vs. 49.6±12.4 years; p=0.982) nor in PAH hemodynamic severity (mean pulmonary artery pressure: 63.1±27.6 vs. 56.6±15.0 mmHg; p=0.486). Patients with LMCAC had larger median pulmonary artery diameter (52.5 [47–60.3] vs 43 [46–50] mm; p=0.024). Among LMCAC patients, 1 (10%) died during follow-up due to neoplastic disease. Among patients without LMCAC, 18 (24%) died (5 [6%] sudden cardiac death; 8 [11%] heart failure; 5 [6%] neoplastic or infectious diseases). Despite LMCAC diagnosis, there were no differences between both groups in time from PAH diagnosis to death (log rank test p=0.38).

Conclusion

LMCAC is a common complication among PAH patients with a PAA. Its early identification and treatment might reduce the rate of sudden cardiac death among PAH patients. Since LMCAC is often asymptomatic regular screening with non-invasive tests should be incorporated to PAH follow-up protocols.

P4672Current outcome of chronic thromboembolic pulmonary hypertension in Spain

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) treatment has evolved over the last decade. Increasing evidence regarding new therapeutic developments has shown clinical benefit among these patients in different scenarios. However, there is scarce information about the long-term impact of these achievements in a real-life population on a national scale. We aimed to analyze the impact of current CTEPH therapies on survival in Spain.

Methods

We prospectively collected epidemiological, clinical and prognostic data from CTEPH patients consecutively included in the Spanish REHAP registry from January 1, 2007, to December 31, 2017. All-cause mortality data were gathered during this period.

Results

Eight hundred thirteen patients were included. The mean age was 61 (15) years and 58.1% were women. Out of the 813 patients, 537 (66%) were referred to an expert PH-center. Overall, 245 (30.1%) patients were selected for surgery and 52 (6.4%) for percutaneous treatment and 452 (60.5%) received medical treatment exclusively with specific PH drugs. Survival rates of patients who underwent an invasive procedure (pulmonary thrombendarterectomy or balloon pulmonary angioplasty) were remarkably high.

Figure 1. Cumulative survival from date

Conclusions

Patients who underwent pulmonary thrombendarterectomy or balloon pulmonary angioplasty associated a better outcome.

Acknowledgement/Funding

We gratefully acknowledge all investigators of the REHAP Registry. We express our gratitude to Actelion, Ferrer, GlaxoSmithKline (GSK) and Merck Sharp

[Incidence and dynamic behavior of spontaneous echocardiographic contrast and atrial thrombi in the transplanted heart]

BACKGROUND

Standard orthotopic heart transplantation produces important anatomic and functional atrial alterations with subsequent thrombotic risk. Therefore the aim of this study was to analyze the prevalence and evolution of spontaneous echocardiography, atrial thrombi and embolic events.

PATIENTS AND METHOD

52 consecutive transplanted patients were analyzed with transesophageal echocardiography and hemodynamic studies performed at 15 days and one year after transplantation.

RESULTS

Spontaneous echocardiography contrast was present in 27 patients (52%). Ten atrial thrombi were observed (19.2%), 9 with spontaneous echocardiography contrast. Six atrial thrombi appeared on day 15 and 4 after one year (with spontaneous echocardiography contrast on the previous study). Using multiple logistic regression analysis left atrial size was the only independent predictor factor for spontaneous echocardiography contrast (OR = 1.27; 95% CI, 1.09-1.54) and was an important predictor factor of atrial thrombi formation (OR = 1.19; 95% CI, 1.04-1.42). Likewise, the main predictor of atrial thrombi was the presence of spontaneous echocardiography contrast (OR = 116; 95% CI, 8.4-999). The hemodynamic pattern did not predict either the presence of spontaneous echocardiography contrast or atrial thrombi. The global incidence of embolic events was 4% less than previously described.

CONCLUSIONS

The incidence of atrial thrombi and spontaneous echocardiographic contrast after standard orthotopic heart transplantation was 19.2% and 52%, respectively. An enlarged atrium and/or spontaneous echocardiography contrast was found to increase the risk of atrial thrombi. Considering the dynamic nature of atrial thrombi formation, periodical transesophageal echocardiography studies are recommended after heart transplantation.