Inclusion of echocardiographic measure of right ventricular function in the non-invasive French pulmonary arterial hypertension risk stratification method

Background

Although preserved right ventricular (RV) function is consistently associated with better survival in pulmonary arterial hypertension (PAH), the French risk assessment method has not yet considered echocardiographic criteria of RV function.

Purpose

In the present study, we tested the value of tricuspid annular plane systolic excursion (TAPSE) measured by echocardiography for non-invasive PAH risk assessment.

Methods

We retrospectively studied a cohort of 306 incident PAH patients treated in two French expert centers who underwent follow-up TAPSE measurement from echocardiographic apical 4-chamber view in addition to previously validated invasive and non-invasive risk stratification variables. The primary composite outcome was 3-year lung transplantation free survival after follow-up assessment.

Results

At re-evaluation, 66% of patients were in NYHA functional class I-II and mean pulmonary arterial pressure, cardiac index, N-Terminal pro brain natriuretic peptide (NTproBNP), and 6-minute walk distance (6MWD) were 40±16 mmHg, 3.5±1.1 L/min/m2, 270 [interquartile range (IQR) 896] ng/L and 401 (IQR 213) meters, respectively. The primary outcome occurred in 58 (19%) patients. In multivariable Cox regression analysis, NYHA functional class I-II (p=0.02), NTproBNP <300 ng/L or BNP <50 ng/L (p=0.02), 6MWD >440m (p=0.049) and TAPSE≥17 mm (p=0.02) were associated with lung transplantation free survival. TAPSE provided similar information over 6MWD when both were used alternatively to stratify PAH patients at low risk (log-rank<0.001); Harrell's c-index 0.73.

Conclusion

Three dichotomized low-risk criteria (TAPSE, 6MWD and NTproBNP or BNP plasma levels) allow non-invasive risk assessment in PAH.

Funding Acknowledgement

Type of funding sources: None. 3-years transplant-free survival

P371 Right ventricle end-systolic remodeling index in patients with atrial septal defect and severe pulmonary arterial hypertension

Background Outcome of patients with atrial septal defect (ASD) and severe pulmonary arterial hypertension (PAH) relates to right ventricular (RV) function.

Magnetic resonance imaging (MRI) remains the gold standard for evaluating the RV function but it is not used routinely. We investigated the relationship between MRI and multiple echocardiography parameters, including the Right Ventricle End-Systolic Remodeling Index (RVESRI), a new prognostic marker in patients with PAH.

Methods 23 patients with ASD and severe PAH (median age 49y.o.[39-59], Sp0 2 92% [90-95], WHO functional class II or III, mean pulmonary artery pressure 51mmHg [40-59]) were included between 2014 and 2018. All patients underwent MRI and echocardiography assessment. Echocardiographic measurements of RV remodeling and function included TAPSE, RV fractional area change (RVFAC), peak systolic velocity of the tricuspid valve (S’TV), right atrial (RA) area, RV strain, Systolic to diastolic ratio, eccentricity index and RVESRI, defined by septum length divided by lateral wall length (Figure 1). Pericardial effusion was noted.

Results Median RV ejection fraction (EF) evaluated with MRI was 46 % [34-59]. RV dysfunction (RVEF < 45%) was observed in 43% of patients. Median RVFAC and

RVESRI were 29.6%[23-34] and 1.6[1.4-1.7] respectively. By spearman correlation, RVFAC and RVESRI were significantly correlated to RVEF (Rho 0.62, p < 0.007 and

Rho -0.51,p < 0.02 respectively). By linear regression, RVFAC and RVESRI were also correlated to RVEF (R 2 =0.36, p < 0.003 and R 2 =0.34, p < 0.08). Pericardial effusion was associated with RV dysfunction (p< 0.008) and a lower RVFAC (p < 0.01). TAPSE, S’TV and RV strain were not correlated with RVEF.

Conclusion RVFAC, RVESRI and pericardial effusion were markers of RV dysfunction in patients with ASD and severe PAH. RVESRI appears as a simple and reliable parameter for follow-up. Its prognostic value in patients with CHD remains to be demonstrated.

Hypertension pulmonaire postembolique

INTRODUCTION

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease characterized by the persistence of thromboemboli obstructing the pulmonary arteries as an organized tissue. The consequence is an increase in pulmonary vascular resistance resulting in pulmonary hypertension (PH) and progressive right heart failure.

BACKGROUND

It is difficult to recognize the postembolic nature of PH because there is no known history of thromboembolic disease in more than 50% of cases. Diagnosis is based on the presence of mismatched segmental defects in the ventilation-perfusion scanning. When CTEPH is suspected, pulmonary angiography and high-resolution CT scan are required to establish the diagnosis and to assess the operability. Pulmonary angiography is always performed in conjunction with a diagnostic right heart catheterization, which is required to confirm the diagnosis of PH and to determine the degree of hemodynamic impairement. If there is a good correlation between the pulmonary vascular resistance and the anatomical obstruction, pulmonary endarterectomy (PEA) must be proposed. Otherwise, vasodilator and antiproliferative treatments and lung transplantation represent interesting alternatives.

VIEWPOINT AND CONCLUSION

PEA remains the treatment of choice for eligible patients. Nevertheless, there is a need to conduct randomized trials to assess the efficacy of novel medical therapies in some situations: (1) in inoperable CTEPH due to distal lesions, (2) before PEA (therapeutic bridge) in patients who are considered "high risk" due to extremely poor hemodynamics, (3) in patients with persistent pulmonary hypertension after surgery.

The efficacy of bosentan in inoperable chronic thromboembolic pulmonary hypertension: a 1-year follow-up study

The treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary endarterectomy (PEA). However, many patients develop a severe progressive small vessel pulmonary arteriopathy that is inaccessible to surgical intervention and is associated with poor survival. The purpose of the present study was to evaluate the medium-term efficacy and safety of the dual endothelin receptor antagonist, bosentan, in inoperable CTEPH. Forty-seven patients with inoperable CTEPH (distal disease or persistent pulmonary hypertension following PEA) underwent evaluation after 1 yr of bosentan therapy. Outcomes included assessment of 6-min walk test (6MWT), haemodynamics and World Health Organization functional classification. Monitoring of serious adverse effects and changes in therapy was undertaken. Patients showed sustained improvements in 6MWT (49+/-8 m), functional classification, cardiac index (+0.2+/-0.07 L.min(-1).m(-2)) and total pulmonary resistance (-139+/-42 dyn.s.cm(-5)). Those patients with persisting pulmonary hypertension following PEA showed the greatest improvement. One-yr survival was 96%, and bosentan was well tolerated with only one patient developing deranged liver function. Although all patients with chronic thromboembolic pulmonary hypertension should be considered for pulmonary endarterectomy, bosentan provides an alternative medical therapy to improve function and delay the progression of this devastating disease in those in whom surgery is not suitable.

Diagnostic et classification des hypertensions artérielles pulmonaires

The clinical classification of types of pulmonary hypertension has made it possible to better standardize the approach to the diagnosis and treatment of patients, to perform clinical studies among homogeneous patients, and to discover common laboratory abnormalities that may serve as markers or help elucidate mechanisms of disease. Pulmonary arterial hypertension groups together different diseases that affect the small-caliber pulmonary arteries and lead to a progressive increase in pulmonary arterial resistance and right heart failure. A specific diagnosis of pulmonary arterial hypertension is generally based on a detailed and methodical clinical evaluation. Pulmonary biopsy is rarely indicated. Work-up in a center specialized in the management of this disease is frequently appropriate when the cause of the hypertension is not clear or when a specific treatment is envisaged.

[Lemierre's syndrome: a case report]

We report a case of Lemierre's syndrome with a pleuropulmonary complication. Lemierre's syndrome is a rare etiology of lung abscess. The diagnosis is clinical and microbiological (anaerobic organisms). This syndrome associates an acute oropharyngeal infection with septic thrombophlebitis of the internal jugular vein (sometimes many days before the lung lesion) and pulmonary abscess formation. Clinicians should be aware of this syndrome that is fatal in 10% of patients, usually after delayed or missed diagnosis. The frequency of Lemierre's syndrome would be higher if antibiotics were given only to pharyngitis patients positive for streptococcus.