101
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Cardiopulmonary Hemodynamics in Pulmonary Hypertension and Heart Failure: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 76:2671-2681. [PMID: 33243385 DOI: 10.1016/j.jacc.2020.10.007] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/21/2020] [Accepted: 10/09/2020] [Indexed: 02/02/2023]
Abstract
Pulmonary hypertension (PH) is an independent risk factor for adverse clinical outcome, particularly in left heart disease (LHD) patients. Recent advances have clarified the mean pulmonary artery pressure (mPAP) range that is above normal and is associated with clinical events, including mortality. This progress has for the first time resulted in a new clinical definition of PH that is evidenced-based, is inclusive of mPAP >20 mm Hg, and emphasizes early diagnosis. Additionally, pulmonary vascular resistance (PVR) 2.2 to 3.0 WU, considered previously to be normal, appears to associate with elevated clinical risk. A revised approach to classifying PH patients as pre-capillary, isolated post-capillary, or combined pre-/post-capillary PH now guides point-of-care diagnosis, risk stratification, and treatment. Exercise hemodynamic or confrontational fluid challenge studies may also aid decision-making for patients with PH-LHD or otherwise unexplained dyspnea. This collective progress in pulmonary vascular and heart failure medicine reinforces the critical importance of accurate hemodynamic assessment.
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102
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New Hemodynamic Insights in Pulmonary Vascular Disease and Heart Failure with Preserved Ejection Fraction. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00900-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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103
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Valle FH, Mohammed B, Wright SP, Bentley R, Fam NP, Mak S. Exercise Right Heart Catheterisation in Cardiovascular Diseases: A Guide to Interpretation and Considerations in the Management of Valvular Heart Disease. ACTA ACUST UNITED AC 2021; 16:e01. [PMID: 33664800 PMCID: PMC7903588 DOI: 10.15420/icr.2020.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 09/01/2020] [Indexed: 12/19/2022]
Abstract
The use of exercise right heart catheterisation for the assessment of cardiovascular diseases has regained attention recently. Understanding physiologic haemodynamic exercise responses is key for the identification of abnormal haemodynamic patterns. Exercise total pulmonary resistance >3 Wood units identifies a deranged haemodynamic response and when total pulmonary resistance exceeds 3 Wood units, an exercise pulmonary artery wedge pressures/cardiac output slope >2 mmHg/l/min indicates the presence of underlying exercise-induced pulmonary hypertension related to left heart disease. In the evolving field of transcatheter interventions for valvular heart disease, exercise right heart catheterisation may objectively unmask symptoms and underlying haemodynamic abnormalities. Further studies are needed on the use of the procedure to inform the selection of patients who might receive the most benefit from transcatheter interventions for valvular heart diseases.
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Affiliation(s)
- Felipe H Valle
- Division of Cardiology, Mount Sinai Hospital/University Health Network Toronto, Canada.,Division of Cardiology, St Michael's Hospital/University of Toronto Toronto, Canada
| | - Basma Mohammed
- Division of Internal Medicine, University of Toronto Toronto, Canada
| | - Stephen P Wright
- Division of Cardiology, Mount Sinai Hospital/University Health Network Toronto, Canada
| | - Robert Bentley
- Division of Cardiology, Mount Sinai Hospital/University Health Network Toronto, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto Toronto, Canada
| | - Neil P Fam
- Division of Cardiology, St Michael's Hospital/University of Toronto Toronto, Canada
| | - Susanna Mak
- Division of Cardiology, Mount Sinai Hospital/University Health Network Toronto, Canada
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104
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The Challenge to Decide between Pulmonary Hypertension Due to Chronic Lung Disease and PAH with Chronic Lung Disease. Diagnostics (Basel) 2021; 11:diagnostics11020311. [PMID: 33671914 PMCID: PMC7918977 DOI: 10.3390/diagnostics11020311] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic lung diseases are strongly associated with pulmonary hypertension (PH), and even mildly elevated pulmonary arterial pressures are associated with increased mortality. Chronic obstructive pulmonary disease (COPD) is the most common chronic lung disease, but few of these patients develop severe PH. Not all these pulmonary pressure elevations are due to COPD, although patients with severe PH due to COPD may represent the largest subgroup within patients with COPD and severe PH. There are also patients with left heart disease (group 2), chronic thromboembolic disease (group 4, CTEPH) and pulmonary arterial hypertension (group 1, PAH) who suffer from COPD or another chronic lung disease as co-morbidity. Because therapeutic consequences very much depend on the cause of pulmonary hypertension, it is important to complete the diagnostic procedures and to decide on the main cause of PH before any decision on PAH drugs is made. The World Symposia on Pulmonary Hypertension (WSPH) have provided guidance for these important decisions. Group 2 PH or complex developmental diseases with elevated postcapillary pressures are relatively easy to identify by means of elevated pulmonary arterial wedge pressures. Group 4 PH can be identified or excluded by perfusion lung scans in combination with chest CT. Group 1 PAH and Group 3 PH, although having quite different disease profiles, may be difficult to discern sometimes. The sixth WSPH suggests that severe pulmonary hypertension in combination with mild impairment in the pulmonary function test (FEV1 > 60 and FVC > 60%), mild parenchymal abnormalities in the high-resolution CT of the chest, and circulatory limitation in the cardiopulmonary exercise test speak in favor of Group 1 PAH. These patients are candidates for PAH therapy. If the patient suffers from group 3 PH, the only possible indication for PAH therapy is severe pulmonary hypertension (mPAP ≥ 35 mmHg or mPAP between 25 and 35 mmHg together with very low cardiac index (CI) < 2.0 L/min/m2), which can only be derived invasively. Right heart catheter investigation has been established nearly 100 years ago, but there are many important details to consider when reading pulmonary pressures in spontaneously breathing patients with severe lung disease. It is important that such diagnostic procedures and the therapeutic decisions are made in expert centers for both pulmonary hypertension and chronic lung disease.
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105
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Messina CMS, Ferreira EVM, Singh I, Fonseca AXC, Ramos RP, Nery LE, Systrom DM, Oliveira RKF, Ota-Arakaki JS. Impact of right ventricular work and pulmonary arterial compliance on peak exercise oxygen uptake in idiopathic pulmonary arterial hypertension. Int J Cardiol 2021; 331:230-235. [PMID: 33545265 DOI: 10.1016/j.ijcard.2021.01.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/26/2020] [Accepted: 01/15/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is associated with increased right ventricular (RV) afterload, RV dysfunction and decreased peak oxygen uptake (pVO2). However, the pulmonary hemodynamic mechanisms measured by exercise right heart catheterization (RHC) that contribute to reduced pVO2 in idiopathic PAH (IPAH) are not completely characterized. Therefore, we sought to evaluate the exercise RHC determinants of pVO2 in patients with IPAH. METHODS 519 consecutive patients with suspected and/or confirmed pulmonary hypertension were prospectively screened to identify 20 patients with IPAH. All IPAH patients were prospectively evaluated with resting and exercise RHC and cardiopulmonary exercise testing. RESULTS 85% of the patients were female; the median age was 34[29-42] years old. At peak exercise, mean pulmonary arterial (PA) pressure was 76 ± 17 mmHg, PA wedge pressure was 14 ± 5 mmHg, cardiac output (CO) was 5.7 ± 1.9 L/min, pulmonary vascular resistance was 959 ± 401 dynes/s/cm5 and PA compliance was 0.9[0.6-1.2] ml/mmHg. On univariate analysis, pVO2 positively correlated to peak CO, peak cardiac index, peak stroke volume index, peak RV stroke work index (RVSWI) and peak oxygen saturation. There was a negative correlation between pVO2 and Δ (rest to peak change) PA compliance. In age-adjusted multivariate model, peak RVSWI (Coefficient = 0.15, Beta = 0.63, 95% CI [0.07-0.22], p < 0.01) and ΔPA compliance (Coefficient = -2.51, Beta = -0.43, 95% CI [-4.34-(-0.68)], p = 0.01) had the best performance predicting pVO2 (R2 = 0.66). CONCLUSIONS In conclusion, a load dependent measurement of RV function (RVSWI) and the pulsatile component of RV afterload (ΔPA compliance) significantly influence pVO2 in IPAH, further highlighting the pivotal role of hemodynamic coupling to IPAH exercise capacity.
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Affiliation(s)
- Carolina M S Messina
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Eloara V M Ferreira
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Angelo X C Fonseca
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Roberta P Ramos
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Luiz E Nery
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Rudolf K F Oliveira
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil.
| | - Jaquelina S Ota-Arakaki
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
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106
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Wernhart S, Hedderich J, Weihe E. Vital capacity and valvular dysfunction could serve as non-invasive predictors to screen for exercise pulmonary hypertension in the elderly based on a new diagnostic score. J Cardiovasc Thorac Res 2021; 13:68-78. [PMID: 33815705 PMCID: PMC8007893 DOI: 10.34172/jcvtr.2021.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/05/2021] [Indexed: 11/09/2022] Open
Abstract
Introduction: Exercise pulmonary hypertension (exPH) has been defined as total pulmonary resistance (TPR) >3 mm Hg/L/min and mean pulmonary artery pressure (mPAP) >30 mm Hg, albeit with a considerable risk of false positives in elderly patients with lower cardiac output during exercise.
Methods: We retrospectively analysed patients with unclear dyspnea receiving right heart catheterisation at rest and exercise (n=244) between January 2015 and January 2020. Lung function testing, blood gas analysis, and echocardiography were performed. We elaborated a combinatorial score to advance the current definition of exPH in an elderly population (mean age 67.0 years±11.9). A stepwise regression model was calculated to non-invasively predict exPH.
Results: Analysis of variables across the achieved peak power allowed the creation of a model for defining exPH, where three out of four criteria needed to be fulfilled: Peak power ≤100 Watt, pulmonary capillary wedge pressure ≥18 mm Hg, pulmonary vascular resistance >3 Wood Units, and mPAP ≥35 mm Hg. The new scoring model resulted in a lower number of exPH diagnoses than the current suggestion (63.1% vs. 78.3%). We present a combinatorial model with vital capacity (VCmax) and valvular dysfunction to predict exPH (sensitivity 93.2%; specificity 44.2%, area under the curve 0.73) based on our suggested criteria. The odds of the presence of exPH were 2.1 for a 1 l loss in VCmax and 3.6 for having valvular dysfunction.
Conclusion: We advance a revised definition of exPH in elderly patients in order to overcome current limitations. We establish a new non-invasive approach to predict exPH by assessing VCmax and valvular dysfunction for early risk stratification in elderly patients.
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Affiliation(s)
- Simon Wernhart
- Department of Cardiology, Fachkrankenhaus Kloster Grafschaft, Schmallenberg, Germany.,University Hospital Essen, University Duisburg-Essen, West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, Hufelandstrasse 55, 45147 Essen, Germany
| | - Jürgen Hedderich
- Medistat-Biomedical Statistics, Medistat GmbH, Kronshagen, Germany
| | - Eberhard Weihe
- Institute of Anatomy and Cell Biology of the Philipps-University Marburg, Germany
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107
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Baratto C, Caravita S, Battista Perego G, Badano LP, Vachiéry JL, Parati G. Systemic Sclerosis and Pulmonary Hypertension: The Great Masquerader. Circ Heart Fail 2021; 14:e007554. [PMID: 33504158 DOI: 10.1161/circheartfailure.120.007554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Claudia Baratto
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy (C.B., S.C., G.B.P., L.P.B., G.P.).,Department of Medicine and Surgery, University of Milano-Bicocca, Italy (C.B., L.P.B., G.P.)
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy (C.B., S.C., G.B.P., L.P.B., G.P.).,Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy (S.C.)
| | - Giovanni Battista Perego
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy (C.B., S.C., G.B.P., L.P.B., G.P.)
| | - Luigi P Badano
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy (C.B., S.C., G.B.P., L.P.B., G.P.).,Department of Medicine and Surgery, University of Milano-Bicocca, Italy (C.B., L.P.B., G.P.)
| | - Jean-Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Belgium (J.-L.V.)
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy (C.B., S.C., G.B.P., L.P.B., G.P.).,Department of Medicine and Surgery, University of Milano-Bicocca, Italy (C.B., L.P.B., G.P.)
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108
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Ton VK, Ramani G, Hsu S, Hopkins CD, Kaczorowski D, Madathil RJ, Mak S, Tedford RJ. High Right Ventricular Afterload Is Associated with Impaired Exercise Tolerance in Patients with Left Ventricular Assist Devices. ASAIO J 2021; 67:39-45. [PMID: 32412930 DOI: 10.1097/mat.0000000000001169] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients with left ventricular assist device (LVAD) have poor exercise tolerance. We aimed to characterize relationship between right ventricular (RV) afterload and exercise capacity, RV reserve, and adaptation to load. Twelve well-compensated LVAD subjects underwent right heart catheterization at rest and during symptom-limited exercise. Cardiopulmonary exercise tests were also performed. Hemodynamics were compared with age- and sex-matched subjects with pulmonary arterial hypertension (PAH) and normal non-athletes. Hemodynamic changes were expressed as Δ(exercise - rest). At rest, LVAD subjects had normal biventricular pressures and cardiac output (CO). On exercise, despite similar increases in pulmonary artery wedge pressure (PAWP) between three groups, RV afterload increased only in LVAD cohort (pulmonary elastance [ΔEa] LVAD: 0.4, PAH: 0.1, normal: 0.1 mmHg/ml, p = 0.0024). This afterload increase coincided with the largest rise in right atrial pressure (RAP), lowest change in RV stroke work index, and smallest CO augmentation (ΔCO LVAD: 1.5, PAH: 4.3, normal: 5.7 L/min, p = 0.0014). Peak VO2 negatively correlated with RV afterload (Ea) (r = -0.8, p = 0.0101), while VE/VCO2 slope had the inverse correlation. During exercise, pulmonary artery pulsatility index worsened while RAP:PAWP ratio was unchanged in LVAD subjects. Well-compensated LVAD patients had poor RV reserve and adaptation to load on exercise compared with PAH and normal subjects.
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Affiliation(s)
- Van-Khue Ton
- From the Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Gautam Ramani
- Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Danielle Hopkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David Kaczorowski
- Department of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Ronson J Madathil
- Department of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Susanna Mak
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON; and
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
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109
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Grünig E, Eichstaedt CA, Seeger R, Benjamin N. Right Heart Size and Right Ventricular Reserve in Pulmonary Hypertension: Impact on Management and Prognosis. Diagnostics (Basel) 2020; 10:E1110. [PMID: 33371372 PMCID: PMC7767391 DOI: 10.3390/diagnostics10121110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 01/23/2023] Open
Abstract
Various parameters reflecting right heart size, right ventricular function and capacitance have been shown to be prognostically important in patients with pulmonary hypertension (PH). In the advanced disease, patients suffer from right heart failure, which is a main reason for an impaired prognosis. Right heart size has shown to be associated with right ventricular function and reserve and is correlated with prognosis in patients with PH. Right ventricular reserve, defined as the ability of the ventricle to adjust to exercise or pharmacologic stress, is expressed by various parameters, which may be determined invasively by right heart catheterization or by stress-Doppler-echocardiography as a noninvasive approach. As the term "right ventricular contractile reserve" may be misleading, "right ventricular output reserve" seems desirable as a preferred term of increase in cardiac output during exercise. Both right heart size and right ventricular reserve have been shown to be of prognostic importance and may therefore be useful for risk assessment in patients with pulmonary hypertension. In this article we aim to display different aspects of right heart size and right ventricular reserve and their prognostic role in PH.
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Affiliation(s)
- Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126 Heidelberg, Germany; (C.A.E.); (R.S.); (N.B.)
- Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), 69126 Heidelberg, Germany
| | - Christina A. Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126 Heidelberg, Germany; (C.A.E.); (R.S.); (N.B.)
- Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), 69126 Heidelberg, Germany
- Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120 Heidelberg, Germany
| | - Rebekka Seeger
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126 Heidelberg, Germany; (C.A.E.); (R.S.); (N.B.)
- Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), 69126 Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Röntgenstrasse 1, 69126 Heidelberg, Germany; (C.A.E.); (R.S.); (N.B.)
- Translational Lung Research Centre Heidelberg (TLRC), German Centre for Lung Research (DZL), 69126 Heidelberg, Germany
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110
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Lange TJ, Borst M, Ewert R, Halank M, Klose H, Leuchte H, Meyer FJ, Seyfarth HJ, Skowasch D, Wilkens H, Held M. [Current Aspects of Definition and Diagnosis of Pulmonary Hypertension]. Pneumologie 2020; 74:847-863. [PMID: 32663892 DOI: 10.1055/a-1199-1548] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
At the 6th World Symposium on Pulmonary Hypertension (WSPH), which took place from February 27 until March 1, 2018 in Nice, scientific progress over the past 5 years in the field of pulmonary hypertension (PH) was presented by 13 working groups. The results of the discussion were published as proceedings towards the end of 2018. One of the major changes suggested by the WSPH was the lowering of the diagnostic threshold for PH from ≥ 25 to > 20 mmHg mean pulmonary arterial pressure, measured by right heart catheterization at rest. In addition, the pulmonary vascular resistance was introduced into the definition of PH, which underlines the importance of cardiac output determination at the diagnostic right heart catheterization.In this article, we discuss the rationale and possible consequences of a changed PH definition in the context of the current literature. Further, we provide a current overview on non-invasive and invasive methods for diagnosis, differential diagnosis, and prognosis of PH, including exercise tests.
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Affiliation(s)
- T J Lange
- Uniklinik Regensburg, Klinik für Innere Medizin II, Bereich Pneumologie, Regensburg
| | - M Borst
- Medizinische Klinik I, Caritas-Krankenhaus, Bad Mergentheim
| | - R Ewert
- Pneumologie, Uniklinik Greifswald, Greifwald
| | - M Halank
- Universitätsklinikum Carl Gustav Carus, Medizinische Klinik 1, Bereich Pneumologie, Dresden
| | - H Klose
- Universitätsklinikum Hamburg-Eppendorf, Abteilung für Pneumologie, Hamburg
| | - H Leuchte
- Klinik der Barmherzigen Schwestern, Krankenhaus Neuwittelsbach, Lehrkrankenhaus der LMU München, München
| | - F J Meyer
- Lungenzentrum München (Bogenhausen-Harlaching), München Klinik gGmbH, München
| | - H-J Seyfarth
- Bereich Pneumologie, Universitätsklinikum Leipzig, Leipzig
| | - D Skowasch
- Universitätsklinikum Bonn, Medizinische Klinik II, Sektion Pneumologie, Bonn
| | - H Wilkens
- Klinik für Innere Medizin V, Universitätsklinikum des Saarlandes, Homburg
| | - M Held
- Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Klinikum Würzburg Mitte, Standort Missioklinik, Würzburg
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111
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Lichtblau M, Bader PR, Saxer S, Berlier C, Schwarz EI, Hasler ED, Furian M, Grünig E, Bloch KE, Ulrich S. Right Atrial Pressure During Exercise Predicts Survival in Patients With Pulmonary Hypertension. J Am Heart Assoc 2020; 9:e018123. [PMID: 33146048 PMCID: PMC7763735 DOI: 10.1161/jaha.120.018123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background We investigated changes in right atrial pressure (RAP) during exercise and their prognostic significance in patients assessed for pulmonary hypertension (PH). Methods and Results Consecutive right heart catheterization data, including RAP recorded during supine, stepwise cycle exercise in 270 patients evaluated for PH, were analyzed retrospectively and compared among groups of patients with PH (mean pulmonary artery pressure [mPAP] ≥25 mm Hg), exercise-induced PH (exPH; resting mPAP <25 mm Hg, exercise mPAP >30 mm Hg, and mPAP/cardiac output >3 Wood Units (WU)), and without PH (noPH). We investigated RAP changes during exercise and survival over a median (quartiles) observation period of 3.7 (2.8-5.6) years. In 152 patients with PH, 58 with exPH, and 60 with noPH, median (quartiles) resting RAP was 8 (6-11), 6 (4-8), and 6 (4-8) mm Hg (P<0.005 for noPH and exPH versus PH). Corresponding peak changes (95% CI) in RAP during exercise were 5 (4-6), 3 (2-4), and -1 (-2 to 0) mm Hg (noPH versus PH P<0.001, noPH versus exPH P=0.027). RAP increase during exercise correlated with mPAP/cardiac output increase (r=0.528, P<0.001). The risk of death or lung transplantation was higher in patients with exercise-induced RAP increase (hazard ratio, 4.24; 95% CI, 1.69-10.64; P=0.002) compared with patients with unaltered or decreasing RAP during exercise. Conclusions In patients evaluated for PH, RAP during exercise should not be assumed as constant. RAP increase during exercise, as observed in exPH and PH, reflects hemodynamic impairment and poor prognosis. Therefore, our data suggest that changes in RAP during exercise right heart catheterization are clinically important indexes of the cardiovascular function.
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Affiliation(s)
- Mona Lichtblau
- Department of Pulmonology University Hospital Zürich Zürich Switzerland
| | - Patrick R Bader
- Department of Pulmonology University Hospital Zürich Zürich Switzerland.,Institute of Intensive Care Medicine University Hospital Zürich Zürich Switzerland
| | - Stéphanie Saxer
- Department of Pulmonology University Hospital Zürich Zürich Switzerland
| | - Charlotte Berlier
- Department of Pulmonology University Hospital Zürich Zürich Switzerland
| | - Esther I Schwarz
- Department of Pulmonology University Hospital Zürich Zürich Switzerland
| | | | - Michael Furian
- Department of Pulmonology University Hospital Zürich Zürich Switzerland
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital Heidelberg Germany
| | - Konrad E Bloch
- Department of Pulmonology University Hospital Zürich Zürich Switzerland
| | - Silvia Ulrich
- Department of Pulmonology University Hospital Zürich Zürich Switzerland
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112
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Lee F, Mielniczuk LM. Pulmonary Hypertension Due to Left Heart Disease-A Practical Approach to Diagnosis and Management. Can J Cardiol 2020; 37:572-584. [PMID: 33217522 DOI: 10.1016/j.cjca.2020.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/01/2020] [Accepted: 11/10/2020] [Indexed: 01/07/2023] Open
Abstract
Pulmonary hypertension (PH) due to left heart disease (LHD) is a frequent complication of heart failure (HF) and is associated with exercise intolerance, poor quality of life, increased risk of hospitalisations, and reduced overall survival. Since the recent Sixth World Symposium on Pulmonary Hypertension in 2018, there have been significant changes in the hemodynamic definitions and clinical classification of PH-LHD. PH-LHD can be subdivided into (1) isolated postcapillary PH (IpcPH) and (2) combined precapillary and postcapillary PH (CpcPH). This categorisation of PH-LHD is important because CpcPH shares certain pathophysiologic, clinical, and hemodynamic characteristics with pulmonary arterial hypertension and is associated with worse outcomes compared with IpcPH. A systematic approach using clinical history and noninvasive investigations is required in the diagnosis of PH-LHD. Right heart catheterisation with and without provocative testing is performed in expert centres and is indicated in selected individuals. Although the definition of IpcPH and CpcPH is based on measurements made with right heart catheterisation, distinguishing between these two entities is not always necessary. Despite strong evidence for medical therapy in patients with pulmonary arterial hypertension, those options have limited benefit in PH-LHD. Expert PH centres in Canada have been established to provide ongoing care for the more complex patient subgroups.
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Affiliation(s)
- Felicity Lee
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Lisa M Mielniczuk
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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113
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Bentley RF, Barker M, Esfandiari S, Wright SP, Valle FH, Granton JT, Mak S. Normal and Abnormal Relationships of Pulmonary Artery to Wedge Pressure During Exercise. J Am Heart Assoc 2020; 9:e016339. [PMID: 33153377 PMCID: PMC7763717 DOI: 10.1161/jaha.120.016339] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Resting right heart catheterization can assess both left heart filling and pulmonary artery (PA) pressures to identify and classify pulmonary hypertension. Although exercise may further elucidate hemodynamic abnormalities, current pulmonary hypertension classifications do not consider the expected interrelationship between PA and left heart filling pressures. This study explored the utility of this relationship to enhance the classification of exercise hemodynamic phenotypes in pulmonary hypertension. Methods and Results Data from 36 healthy individuals (55, 50–60 years, 50% male) and 85 consecutive patients (60, 49–71 years, 48% male) with dyspnea and/or suspected pulmonary hypertension of uncertain etiology were analyzed. Right heart catheterization was performed at rest and during semiupright submaximal cycling. To classify exercise phenotypes in patients, upper 95% CIs were identified from the healthy individuals for the change from rest to exercise in mean PA pressure over cardiac output (ΔmPAP/ΔCO ≤3.2 Wood units [WU]), pulmonary artery wedge pressure over CO (ΔPAWP/ΔCO ≤2 mm Hg/L per minute), and exercise PA pulse pressure over PAWP (PP/PAWP ≤2.5). Among patients with a ΔmPAP/ΔCO ≤3.2 WU, the majority (84%) demonstrated a ΔPAWP/ΔCO ≤2 mm Hg/L per minute, yet 23% demonstrated an exercise PP/PAWP >2.5. Among patients with a ΔmPAP/ΔCO >3.2 WU, 37% had an exercise PP/PAWP >2.5 split between ΔPAWP/ΔCO groups. Patients with normal hemodynamic classification declined from 52% at rest to 36% with exercise. Conclusions The addition of PP/PAWP to classify exercise hemodynamics uncovers previously unrecognized abnormal phenotypes within each ΔmPAP/ΔCO group. Our study refines abnormal exercise hemodynamic phenotypes based on an understanding of the interrelationship between PA and left heart filling pressures.
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Affiliation(s)
- Robert F Bentley
- Division of Cardiology Mount Sinai Hospital, Sinai Health Toronto Ontario Canada.,Faculty of Kinesiology and Physical Education University of Toronto Ontario Canada
| | - Madeleine Barker
- Division of Cardiology Mount Sinai Hospital, Sinai Health Toronto Ontario Canada
| | - Sam Esfandiari
- Division of Cardiology Mount Sinai Hospital, Sinai Health Toronto Ontario Canada.,Institute of Medical Science University of Toronto Ontario Canada
| | - Stephen P Wright
- Division of Cardiology Mount Sinai Hospital, Sinai Health Toronto Ontario Canada.,School of Health and Exercise Sciences University of British Columbia Kelowna British Columbia Canada
| | - Felipe H Valle
- Division of Cardiology Mount Sinai Hospital, Sinai Health Toronto Ontario Canada.,Division of Cardiology St. Michael's Hospital, Unity Health Toronto Ontario Canada
| | - John T Granton
- Institute of Medical Science University of Toronto Ontario Canada.,Division of Respirology University Health Network Toronto Ontario Canada
| | - Susanna Mak
- Division of Cardiology Mount Sinai Hospital, Sinai Health Toronto Ontario Canada.,Institute of Medical Science University of Toronto Ontario Canada
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114
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Ho JE, Redfield MM, Lewis GD, Paulus WJ, Lam CSP. Deliberating the Diagnostic Dilemma of Heart Failure With Preserved Ejection Fraction. Circulation 2020; 142:1770-1780. [PMID: 33136513 DOI: 10.1161/circulationaha.119.041818] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
There is a lack of consensus on how we define heart failure with preserved ejection fraction (HFpEF), with wide variation in diagnostic criteria across society guidelines. This lack of uniformity in disease definition stems in part from an incomplete understanding of disease pathobiology, phenotypic heterogeneity, and natural history. We review current knowledge gaps and existing diagnostic tools and algorithms. We present a simple approach to implement these tools within the constraints of the current knowledge base, addressing separately (1) hospitalized individuals with rest congestion, where diagnosis is more straightforward; and (2) individuals with exercise intolerance, where diagnosis is more complex. Here, a potential role for advanced or provocative testing, including evaluation of hemodynamic responses to exercise is considered. More importantly, we propose focus areas for future studies to develop accurate and feasible diagnostic tools for HFpEF, including animal models that recapitulate human HFpEF, and human studies that both address a fundamental understanding of HFpEF pathobiology, and new diagnostic approaches and tools, as well. In sum, there is an urgent need to more accurately define the syndrome of HFpEF to inform diagnosis, patient selection for clinical trials, and, ultimately, future therapeutic approaches.
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Affiliation(s)
- Jennifer E Ho
- Corrigan Minehan Heart Center (J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston.,Cardiovascular Research Center (JE.H.), Massachusetts General Hospital, Harvard Medical School, Boston.,Division of Cardiology, Department of Medicine (J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | | | - Gregory D Lewis
- Corrigan Minehan Heart Center (J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston.,Division of Cardiology, Department of Medicine (J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Walter J Paulus
- Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, The Netherlands (W.J.P.)
| | - Carolyn S P Lam
- National Heart Centre Singapore (C.S.P.L.).,National Heart Center Singapore & Duke-NUS Medical School Singapore (C.S.P.L.).,Department of Cardiology, University Medical Centre Groningen, University of Groningen, The Netherlands (C.S.P.L.).,The George Institute for Global Health, Sydney, Australia (C.S.P.L.)
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115
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Methods to improve the yield of right heart catheterization in pulmonary hypertension. RESPIRATORY MEDICINE: X 2020. [DOI: 10.1016/j.yrmex.2020.100015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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116
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Reddy YNV, Obokata M, Wiley B, Koepp KE, Jorgenson CC, Egbe A, Melenovsky V, Carter RE, Borlaug BA. The haemodynamic basis of lung congestion during exercise in heart failure with preserved ejection fraction. Eur Heart J 2020; 40:3721-3730. [PMID: 31609443 DOI: 10.1093/eurheartj/ehz713] [Citation(s) in RCA: 135] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/11/2019] [Accepted: 10/07/2019] [Indexed: 12/21/2022] Open
Abstract
AIMS Increases in extravascular lung water (EVLW) during exercise contribute to symptoms, morbidity, and mortality in patients with heart failure and preserved ejection fraction (HFpEF), but the mechanisms leading to pulmonary congestion during exercise are not well-understood. METHODS AND RESULTS Compensated, ambulatory patients with HFpEF (n = 61) underwent invasive haemodynamic exercise testing using high-fidelity micromanometers with simultaneous lung ultrasound, echocardiography, and expired gas analysis at rest and during submaximal exercise. The presence or absence of EVLW was determined by lung ultrasound to evaluate for sonographic B-line artefacts. An increase in EVLW during exercise was observed in 33 patients (HFpEFLW+, 54%), while 28 (46%) did not develop EVLW (HFpEFLW-). Resting left ventricular function was similar in the groups, but right ventricular (RV) dysfunction was two-fold more common in HFpEFLW+ (64 vs. 31%), with lower RV systolic velocity and RV fractional area change. As compared to HFpEFLW-, the HFpEFLW+ group displayed higher pulmonary capillary wedge pressure (PCWP), higher pulmonary artery (PA) pressures, worse RV-PA coupling, and higher right atrial (RA) pressures during exercise, with increased haemoconcentration indicating greater loss of water from the vascular space. The development of lung congestion during exercise was significantly associated with elevations in PCWP and RA pressure as well as impairments in RV-PA coupling (area under the curve values 0.76-0.84). CONCLUSION Over half of stable outpatients with HFpEF develop increases in interstitial lung water, even during submaximal exercise. The acute development of lung congestion is correlated with increases in pulmonary capillary hydrostatic pressure that favours fluid filtration, and systemic venous hypertension due to altered RV-PA coupling, which may interfere with fluid clearance. CLINICAL TRIAL REGISTRATION NCT02885636.
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Affiliation(s)
- Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, 200 First Street SW, MN, USA
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, 200 First Street SW, MN, USA
| | - Brandon Wiley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, 200 First Street SW, MN, USA
| | - Katlyn E Koepp
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, 200 First Street SW, MN, USA
| | - Caitlin C Jorgenson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, 200 First Street SW, MN, USA
| | - Alexander Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, 200 First Street SW, MN, USA
| | - Vojtech Melenovsky
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, 200 First Street SW, MN, USA
| | - Rickey E Carter
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, 200 First Street SW, MN, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, 200 First Street SW, MN, USA
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117
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Babu AS, Morris NR. Patients support exercise training and rehabilitation-what more should we be doing to ensure cardiopulmonary rehabilitation is more readily available for those with pulmonary hypertension? Pulm Circ 2020; 10:2045894020975312. [PMID: 33354318 PMCID: PMC7734525 DOI: 10.1177/2045894020975312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Abraham S. Babu
- Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Karnataka, India
- Department of Cardiology – Austin Health, University of Melbourne, Melbourne, Australia
- Healthy Living for Pandemic Event Protection (HL-PIVOT) Network, Chicago, IL, USA
| | - Norman R. Morris
- Healthy Living for Pandemic Event Protection (HL-PIVOT) Network, Chicago, IL, USA
- Allied Health Research Collaborative, The Prince Charles Hospital, Chermside, Griffith University, Nathan, Australia
- School of Allied Health Sciences and Menzies Health Institute, Griffith University, Nathan, Australia
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118
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Kapłon-Cieślicka A, Kupczyńska K, Dobrowolski P, Michalski B, Jaguszewski MJ, Banasiak W, Burchardt P, Chrzanowski Ł, Darocha S, Domienik-Karłowicz J, Drożdż J, Fijałkowski M, Filipiak KJ, Gruchała M, Jankowska EA, Jankowski P, Kasprzak JD, Kosmala W, Lipiec P, Mitkowski P, Mizia-Stec K, Szymański P, Tycińska A, Wańha W, Wybraniec M, Witkowski A, Ponikowski P, "Club 30" Of The Polish Cardiac Society OBO. On the search for the right definition of heart failure with preserved ejection fraction. Cardiol J 2020; 27:449-468. [PMID: 32986238 PMCID: PMC8078979 DOI: 10.5603/cj.a2020.0124] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/21/2020] [Accepted: 09/10/2020] [Indexed: 12/22/2022] Open
Abstract
The definition of heart failure with preserved ejection fraction (HFpEF) has evolved from a clinically based "diagnosis of exclusion" to definitions focused on objective evidence of diastolic dysfunction and/or elevated left ventricular filling pressures. Despite advances in our understanding of HFpEF pathophysiology and the development of more sophisticated imaging modalities, the diagnosis of HFpEF remains challenging, especially in the chronic setting, given that symptoms are provoked by exertion and diagnostic evaluation is largely conducted at rest. Invasive hemodynamic study, and in particular - invasive exercise testing, is considered the reference method for HFpEF diagnosis. However, its use is limited as opposed to the high number of patients with suspected HFpEF. Thus, diagnostic criteria for HFpEF should be principally based on non-invasive measurements. As no single non-invasive variable can adequately corroborate or refute the diagnosis, different combinations of clinical, echocardiographic, and/or biochemical parameters have been introduced. Recent years have brought an abundance of HFpEF definitions. Here, we present and compare four of them: 1) the 2016 European Society of Cardiology criteria for HFpEF; 2) the 2016 echocardiographic algorithm for diagnosing diastolic dysfunction; 3) the 2018 evidence-based H2FPEF score; and 4) the most recent, 2019 Heart Failure Association HFA-PEFF algorithm. These definitions vary in their approach to diagnosis, as well as sensitivity and specificity. Further studies to validate and compare the diagnostic accuracy of HFpEF definitions are warranted. Nevertheless, it seems that the best HFpEF definition would originate from a randomized clinical trial showing a favorable effect of an intervention on prognosis in HFpEF.
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Affiliation(s)
- Agnieszka Kapłon-Cieślicka
- "Club 30", Polish Cardiac Society, Poland.
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland.
| | - Karolina Kupczyńska
- "Club 30", Polish Cardiac Society, Poland
- I Department and Chair of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Piotr Dobrowolski
- "Club 30", Polish Cardiac Society, Poland
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Błażej Michalski
- "Club 30", Polish Cardiac Society, Poland
- I Department and Chair of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Miłosz J Jaguszewski
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, Medical University of Gdansk, Gdańsk, Poland
| | - Waldemar Banasiak
- "Club 30", Polish Cardiac Society, Poland
- Department of Cardiology, 4th Military Hospital, Wrocław, Poland
| | - Paweł Burchardt
- "Club 30", Polish Cardiac Society, Poland
- Department of Hypertension, Angiology, and Internal Medicine, Poznan University of Medical Sciences, Poznań, Poland, and Department of Cardiology, J. Strus Hospital, Poznań, Poland
| | - Łukasz Chrzanowski
- "Club 30", Polish Cardiac Society, Poland
- I Department and Chair of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Szymon Darocha
- "Club 30", Polish Cardiac Society, Poland
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, Otwock, Poland
| | - Justyna Domienik-Karłowicz
- "Club 30", Polish Cardiac Society, Poland
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Jarosław Drożdż
- "Club 30", Polish Cardiac Society, Poland
- Department of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Marcin Fijałkowski
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, Medical University of Gdansk, Gdańsk, Poland
| | - Krzysztof J Filipiak
- "Club 30", Polish Cardiac Society, Poland
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Gruchała
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, Medical University of Gdansk, Gdańsk, Poland
| | - Ewa A Jankowska
- "Club 30", Polish Cardiac Society, Poland
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland, and Center for Heart Diseases, University Hospital, Wrocław, Poland
| | - Piotr Jankowski
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, Interventional Electrocardiology and Hypertension, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Jarosław D Kasprzak
- "Club 30", Polish Cardiac Society, Poland
- I Department and Chair of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Wojciech Kosmala
- "Club 30", Polish Cardiac Society, Poland
- Chair and Department of Cardiology, Wroclaw Medical University, Wrocław, Poland, and Center for Heart Diseases, University Hospital, Wrocław, Poland
| | - Piotr Lipiec
- "Club 30", Polish Cardiac Society, Poland
- Department of Rapid Cardiac Diagnostics, Chair of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Przemysław Mitkowski
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, Chair of Cardiology, Karol Marcinkowski University of Medical Sciences, Poznań, Poland
| | - Katarzyna Mizia-Stec
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Piotr Szymański
- "Club 30", Polish Cardiac Society, Poland
- Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of the Interior in Warsaw, Warsaw, Poland
| | - Agnieszka Tycińska
- "Club 30", Polish Cardiac Society, Poland
- Department of Cardiology, Medical University of Bialystok, Białystok, Poland
| | - Wojciech Wańha
- "Club 30", Polish Cardiac Society, Poland
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Maciej Wybraniec
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Adam Witkowski
- "Club 30", Polish Cardiac Society, Poland
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Piotr Ponikowski
- "Club 30", Polish Cardiac Society, Poland
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland, and Center for Heart Diseases, University Hospital, Wrocław, Poland
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119
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Exercise Pulmonary Resistances Predict Long-Term Survival in Systemic Sclerosis. Chest 2020; 159:781-790. [PMID: 32931822 DOI: 10.1016/j.chest.2020.08.2110] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/19/2020] [Accepted: 08/22/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Pulmonary hemodynamics during exercise may reveal early pulmonary vascular disease and may be of clinical and prognostic relevance in systemic sclerosis (SSc). We aimed to assess the prognostic relevance of exercise pulmonary resistances in patients with SSc with no or mildly increased mean pulmonary arterial pressure (mPAP). RESEARCH QUESTION Are pulmonary resistances at peak exercise independent predictors of mortality in systemic sclerosis? STUDY DESIGN AND METHODS All SSc patients with resting mPAP < 25 mm Hg and at least one year of follow-up data who underwent symptom-limited exercise right heart catheterization between April 2005 and December 2018 were analyzed retrospectively. Age-adjusted Cox regression analysis was used to evaluate the association between pulmonary resistances and all-cause mortality. RESULTS The cohort consisted of 80 patients: 73 women and 7 men with a mean age of 57 years (interquartile range [IQR], 47-67 years) and a mean follow-up time of 10.4 years (IQR, 8.5-11.8 years). At baseline, resting mPAP of ≤ 20 mm Hg and 21 to 24 mm Hg was found in 68 and 12 patients, respectively. Pulmonary vascular resistance (PVR) and total pulmonary resistance (TPR) at peak exercise were associated significantly with mortality (P = .006 [hazard ratio (HR), 2.20; 95% CI, 1.26-3.87] and P = .026 [HR, 1.56; 95% CI, 1.06-2.29]), whereas resting PVR and TPR were not (P = .087 [HR, 2.27; 95% CI, 0.89-5.83] and P = .079 [HR, 1.88; 95% CI, 0.93-3.80]). The mPAP per cardiac output (CO) and transpulmonary gradient (TPG) per CO slopes were associated significantly with mortality (P = .047 [HR, 1.14; 95% CI, 1.002-1.286] and P = .034 [HR, 1.34; 95% CI, 1.02-1.76]) as well. The area under the receiver operating characteristic curve for exercise PVR to predict 10-year mortality was 0.917 (95% CI, 0.797-1.000). INTERPRETATION PVR and TPR at peak exercise, mPAP/CO slope, and TPG/CO slope are predictors of age-adjusted long-term mortality in SSc patients with no or mildly increased pulmonary arterial pressure.
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120
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Faure M, Valentin S, Zysman M, Sitbon O, Peretti L, Guillaumot A, Gomez E, Huttin O, Selton-Suty C, Chabot F, Chaouat A. Exercise Hemodynamics in the Prognosis of Patients with Pulmonary Arterial Hypertension. Respiration 2020; 99:678-685. [PMID: 32862181 DOI: 10.1159/000509144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/03/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Assessment of prognosis is of major importance when deciding on a therapeutic strategy in patients with pulmonary arterial hypertension (PAH). OBJECTIVES The aim of this study was to investigate the prognostic value of pulmonary hemodynamics during exercise and changes during treatment in patients with PAH. METHODS Consecutive incident patients (n = 49) with PAH undergoing right heart catheterization at rest and during a constant workload cycle exercise in supine position were included. Predictors of survival were identified at baseline using Cox proportional hazard regression models in a univariate analysis unadjusted and adjusted for age and gender. RESULTS During a median follow-up period of 42 months, 13 (27%) of the 49 patients studied died. Two predictors of death were found: rest-to-exercise changes in heart rate and systolic pulmonary artery pressure. Adjusted hazard ratios were 0.92 (95% CI 0.86-0.99) and 0.93 (95% CI 0.88-0.99), respectively. These 2 variables were correlated with each other (r = 0.55, p < 0.001). CONCLUSIONS Rest-to-exercise changes in heart rate and systolic pulmonary artery pressure measured at diagnosis are predictors of survival in patients with PAH. These measurements taken from an exercise test reflect right ventricular function.
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Affiliation(s)
- Morgane Faure
- Pôle des Spécialités Médicales/Département de Pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Simon Valentin
- Pôle des Spécialités Médicales/Département de Pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France, .,Inserm UMR_S1116, Faculté de Médecine de Nancy, Université de Lorraine, Vandœuvre-lès-Nancy, France,
| | | | - Olivier Sitbon
- Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM UMR S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Laura Peretti
- Pôle des Spécialités Médicales/Département de Pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Anne Guillaumot
- Pôle des Spécialités Médicales/Département de Pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Emmanuel Gomez
- Pôle des Spécialités Médicales/Département de Pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Olivier Huttin
- Département de Cardiologie, CHRU de Nancy, Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu, Nancy, France
| | - Christine Selton-Suty
- Département de Cardiologie, CHRU de Nancy, Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu, Nancy, France
| | - François Chabot
- Pôle des Spécialités Médicales/Département de Pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France.,Inserm UMR_S1116, Faculté de Médecine de Nancy, Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - Ari Chaouat
- Pôle des Spécialités Médicales/Département de Pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France.,Inserm UMR_S1116, Faculté de Médecine de Nancy, Université de Lorraine, Vandœuvre-lès-Nancy, France
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Mandoli GE, Sciaccaluga C, Bandera F, Cameli P, Esposito R, D'Andrea A, Evola V, Sorrentino R, Malagoli A, Sisti N, Nistor D, Santoro C, Bargagli E, Mondillo S, Galderisi M, Cameli M. Cor pulmonale: the role of traditional and advanced echocardiography in the acute and chronic settings. Heart Fail Rev 2020; 26:263-275. [PMID: 32860180 PMCID: PMC7895796 DOI: 10.1007/s10741-020-10014-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cor pulmonale is the condition in which the right ventricle undergoes morphological and/or functional changes due to diseases that affect the lungs, the pulmonary circulation, or the breathing process. Depending on the speed of onset of the pathological condition and subsequent effects on the right ventricle, it is possible to distinguish the acute cor pulmonale from the chronic type of disease. Echocardiography plays a central role in the diagnostic and therapeutic work-up of these patients, because of its non-invasive nature and wide accessibility, providing its greatest usefulness in the acute setting. It also represents a valuable tool for tracking right ventricular function in patients with cor pulmonale, assessing its stability, deterioration, or improvement during follow-up. In fact, not only it provides parameters with prognostic value, but also it can be used to assess the efficacy of treatment. This review attempts to provide the current standards of an echocardiographic evaluation in both acute and chronic cor pulmonale, focusing also on the findings present in the most common pathologies causing this condition.
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Affiliation(s)
- Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, AOUS Policlinico Santa Maria alle Scotte, University of Siena, Viale Bracci 1, 53100, Siena, Italy.
| | - Carlotta Sciaccaluga
- Department of Medical Biotechnologies, Division of Cardiology, AOUS Policlinico Santa Maria alle Scotte, University of Siena, Viale Bracci 1, 53100, Siena, Italy
| | - Francesco Bandera
- Cardiology University Department, Heart Failure Unit, IRCCS, Policlinico San Donato, San Donato Milanese and Department of Biomedical Sciences for Health, University of Milano, Milan, Italy
| | - Paolo Cameli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences and Neuroscience, University of Siena, Siena, Italy
| | - Roberta Esposito
- Department of Advanced Biomedical Science, Federico II University Hospital Naples, Naples, Italy
| | - Antonello D'Andrea
- Cardiology Department, Echocardiography Lab and Rehabilitation Unit, Monaldi Hospital, Second University of Naples, Naples, Italy
| | - Vincenzo Evola
- Department of Health Promotion Sciences, Maternal-Infant Care, Internal Medicine and Specialities of Excellence "G. D'Alessandro", University of Palermo, Cardiology Unit, University Hospital P. Giaccone, Palermo, Italy
| | - Regina Sorrentino
- Department of Advanced Biomedical Science, Federico II University Hospital Naples, Naples, Italy
| | - Alessandro Malagoli
- Division of Cardiology, Nephro-Cardiovascular Department, "S. Agostino-Estense" Public Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicolò Sisti
- Department of Medical Biotechnologies, Division of Cardiology, AOUS Policlinico Santa Maria alle Scotte, University of Siena, Viale Bracci 1, 53100, Siena, Italy
| | - Dan Nistor
- Institute for Emergency Cardiovascular Diseases and Transplant Targu Mures, Targu Mures, Romania
| | - Ciro Santoro
- Department of Advanced Biomedical Science, Federico II University Hospital Naples, Naples, Italy
| | - Elena Bargagli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences and Neuroscience, University of Siena, Siena, Italy
| | - Sergio Mondillo
- Department of Medical Biotechnologies, Division of Cardiology, AOUS Policlinico Santa Maria alle Scotte, University of Siena, Viale Bracci 1, 53100, Siena, Italy
| | - Maurizio Galderisi
- Department of Advanced Biomedical Science, Federico II University Hospital Naples, Naples, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, AOUS Policlinico Santa Maria alle Scotte, University of Siena, Viale Bracci 1, 53100, Siena, Italy
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Laveneziana P, Weatherald J. Pulmonary Vascular Disease and Cardiopulmonary Exercise Testing. Front Physiol 2020; 11:964. [PMID: 32848882 PMCID: PMC7425313 DOI: 10.3389/fphys.2020.00964] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/15/2020] [Indexed: 12/11/2022] Open
Abstract
Cardiopulmonary exercise testing (CPET) is of great interest and utility for clinicians dealing Pulmonary Hypertension (PH) in several ways, including: helping with differential diagnosis, evaluating exercise intolerance and its underpinning mechanisms, accurately assessing exertional dyspnea and unmasking its underlying often non-straightforward mechanisms, generating prognostic indicators. Pathophysiologic anomalies in PH can range from reduced cardiac output and aerobic capacity, to inefficient ventilation, dyspnea, dynamic hyperinflation, and locomotor muscle dysfunction. CPET can magnify the PH-related pathophysiologic anomalies and has a major role in the management of PH patients.
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Affiliation(s)
- Pierantonio Laveneziana
- Sorbonne Université, INSERM, UMR S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Sites Pitié-Salpêtrière, Saint-Antoine et Tenon, Service des Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée (Département R3S), Paris, France
| | - Jason Weatherald
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
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123
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Mukherjee M, Mathai SC. Exercise Echocardiography as a Screening Tool in Systemic Sclerosis. J Rheumatol 2020; 47:643-645. [PMID: 32358166 DOI: 10.3899/jrheum.191249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
| | - Stephen C Mathai
- Johns Hopkins University, Division of Pulmonary and Critical Care Medicine, Baltimore, Maryland, USA
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124
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D'Alto M, Badesch D, Bossone E, Borlaug BA, Brittain E, Humbert M, Naeije R. A Fluid Challenge Test for the Diagnosis of Occult Heart Failure. Chest 2020; 159:791-797. [PMID: 32805242 DOI: 10.1016/j.chest.2020.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/23/2020] [Accepted: 08/10/2020] [Indexed: 12/20/2022] Open
Abstract
A right heart catheterization with measurements of pulmonary artery wedge pressure (PAWP) may be necessary for the diagnosis of left heart failure as a cause of pulmonary hypertension or unexplained dyspnea. Diagnostic cutoff values are a PAWP of ≥ 15 mm Hg at rest or a PAWP of ≥ 25 mm Hg during exercise. However, accurate measurement of PAWP can be challenging and heart failure may be occult. Left heart catheterization, with measurement of left ventricular end-diastolic pressure, may also be indecisive. Measurements are then best repeated in stress conditions. Exercise is an option, but the equipment is not universally available, and interpretation can be difficult in patients with wide respiratory pressure swings. An alternative is offered by a fluid challenge. Studies have gathered data supporting infusion of 500 mL or 7 mL/kg saline and a PAWP of 18 mm Hg as a diagnostic cutoff. The procedure is simple and does not take much catheterization laboratory time. Combining echocardiography with invasive measurements may increase the diagnostic accuracy of diastolic dysfunction. Cardiac output after a fluid challenge may be of prognostic relevance.
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Affiliation(s)
- Michele D'Alto
- Department of Cardiology, Monaldi Hospital - University "L. Vanvitelli," Naples, Italy
| | - David Badesch
- Divisions of Pulmonary Sciences and Critical Care Medicine and Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Eduardo Bossone
- Department of Cardiology, A. Cardarelli Hospital, Naples, Italy
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Evan Brittain
- Department of Medicine and Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University Medical Center, Nashville, TN
| | - Marc Humbert
- Université Paris-Saclay, INSERM UMR_S 999, Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Robert Naeije
- Department of Pathophysiology, Free University of Brussels, Brussels, Belgium.
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125
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Nayor M, Houstis NE, Namasivayam M, Rouvina J, Hardin C, Shah RV, Ho JE, Malhotra R, Lewis GD. Impaired Exercise Tolerance in Heart Failure With Preserved Ejection Fraction: Quantification of Multiorgan System Reserve Capacity. JACC. HEART FAILURE 2020; 8:605-617. [PMID: 32535122 PMCID: PMC7395858 DOI: 10.1016/j.jchf.2020.03.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/04/2020] [Accepted: 03/05/2020] [Indexed: 02/07/2023]
Abstract
Exercise intolerance is a principal feature of heart failure with preserved ejection fraction (HFpEF), whether or not there is evidence of congestion at rest. The degree of functional limitation observed in HFpEF is comparable to patients with advanced heart failure and reduced ejection fraction. Exercise intolerance in HFpEF is characterized by impairments in the physiological reserve capacity of multiple organ systems, but the relative cardiac and extracardiac deficits vary among individuals. Detailed measurements made during exercise are necessary to identify and rank-order the multiorgan system limitations in reserve capacity that culminate in exertional intolerance in a given person. We use a case-based approach to comprehensively review mechanisms of exercise intolerance and optimal approaches to evaluate exercise capacity in HFpEF. We also summarize recent and ongoing trials of novel devices, drugs, and behavioral interventions that aim to improve specific exercise measures such as peak oxygen uptake, 6-min walk distance, heart rate, and hemodynamic profiles in HFpEF. Evaluation during the clinically relevant physiological perturbation of exercise holds promise to improve the precision with which HFpEF is defined and therapeutically targeted.
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Affiliation(s)
- Matthew Nayor
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nicholas E Houstis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mayooran Namasivayam
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Rouvina
- Pulmonary Critical Care Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Charles Hardin
- Pulmonary Critical Care Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Ravi V Shah
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jennifer E Ho
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Rajeev Malhotra
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Gregory D Lewis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Pulmonary Critical Care Unit, Massachusetts General Hospital, Boston, Massachusetts; Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts.
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127
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Ratwatte S, Anderson J, Strange G, Corrigan C, Collins N, Celermajer DS, Dwyer N, Feenstra J, Keating D, Kotlyar E, Lavender M, Whitford H, Whyte K, Williams T, Wrobel JP, Keogh A, Lau EM. Pulmonary arterial hypertension with below threshold pulmonary vascular resistance. Eur Respir J 2020; 56:13993003.01654-2019. [PMID: 32341105 DOI: 10.1183/13993003.01654-2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 03/24/2020] [Indexed: 12/25/2022]
Abstract
Pulmonary vascular resistance (PVR) >3 Wood units is a criterion of the haemodynamic definition of pulmonary arterial hypertension (PAH). However, this cut-off is conservative and arbitrarily defined. Data is lacking on the natural history, response to therapy and survival of patients diagnosed with precapillary pulmonary hypertension (PH) with mild or borderline elevation of PVR.In Australia, PAH therapy could be prescribed solely on mean pulmonary arterial pressure (PAP) and pulmonary arterial wedge pressure (PAWP) criteria. Using the Australian and New Zealand Pulmonary Hypertension Registry, we aimed to study a population diagnosed with PAH between January 2004 and December 2017 with the pre-defined haemodynamic characteristics of mean PAP ≥25 mmHg, PAWP ≤15 mmHg and PVR <3 Wood units.Eighty-two patients met the pre-defined haemodynamic inclusion criteria (mean age 63±11 years; 67 females). Underlying aetiologies included idiopathic disease (n=39), connective tissue disease (CTD; n=42) and HIV infection (n=1). At diagnosis, mean PAP was 27 mmHg (interquartile range (IQR) 25-30 mmHg), PAWP 13 mmHg (IQR 11-14 mmHg) and PVR 2.2 Wood units (IQR 1.9-2.7 Wood units). Baseline 6-min walk distance (6MWD) was 352 m (IQR 280-416 m) and 77% of subjects were in New York Heart Association (NYHA) functional class 3 or 4. All patients were commenced on initial monotherapy with an endothelin receptor antagonist (ERA; n=66) or phosphodiesterase type-5 inhibitor (PDE5i; n=16). At first re-evaluation, 6MWD increased by 46 m (IQR 7-96 m) and 35% of subjects demonstrated improvement in NYHA functional class. After a median follow-up of 65 months (IQR 32-101 months), 18 out of 82 subjects (22.0%) had died, with estimated 1-year and 5-year survival rates of 98% and 84%, respectively. Death attributed to PAH occurred in six out of these 18 patients (33.3%, 7% of total cohort).Patients with precapillary PH and "borderline" PVR falling outside the current definition have adverse outcomes. Such patients appear to respond to PAH therapy; however, this requires further study in randomised trials.
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Affiliation(s)
- Seshika Ratwatte
- Dept of Cardiology, Concord Repatriation and General Hospital, Concord, Australia
| | - James Anderson
- Respiratory Dept, Sunshine Coast University Hospital, Birtyna, Australia
| | - Geoffrey Strange
- School of Medicine, University of Notre Dame, Fremantle, Australia.,Pulmonary Hypertension Society of Australia and New Zealand
| | - Carolyn Corrigan
- Heart Transplant Unit, St Vincent's Hospital, Darlinghurst, Australia
| | | | | | - Nathan Dwyer
- Dept of Cardiology, Royal Hobart Hospital, Hobart, Australia
| | - John Feenstra
- Queensland Lung Transplant Service, Prince Charles Hospital, Chermside, Australia
| | - Dominic Keating
- Dept of Allergy, Immunology and Respiratory Medicine, The Alfred Hospital, Melbourne, Australia
| | - Eugene Kotlyar
- Heart Transplant Unit, St Vincent's Hospital, Darlinghurst, Australia
| | - Melanie Lavender
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Murdoch, Australia
| | - Helen Whitford
- Dept of Allergy, Immunology and Respiratory Medicine, The Alfred Hospital, Melbourne, Australia
| | - Ken Whyte
- Greenlane Clinical Centre, Auckland City Hospital, Auckland, New Zealand
| | - Trevor Williams
- Dept of Allergy, Immunology and Respiratory Medicine, The Alfred Hospital, Melbourne, Australia
| | - Jeremy P Wrobel
- School of Medicine, University of Notre Dame, Fremantle, Australia.,Advanced Lung Disease Unit, Fiona Stanley Hospital, Murdoch, Australia
| | - Anne Keogh
- Heart Transplant Unit, St Vincent's Hospital, Darlinghurst, Australia
| | - Edmund M Lau
- Sydney Medical School, University of Sydney, Camperdown, Australia
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128
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Kikuchi H, Goda A, Takeuchi K, Inami T, Kohno T, Sakata K, Soejima K, Satoh T. Exercise intolerance in chronic thromboembolic pulmonary hypertension after pulmonary angioplasty. Eur Respir J 2020; 56:13993003.01982-2019. [PMID: 32312861 DOI: 10.1183/13993003.01982-2019] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 03/26/2020] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Exercise pulmonary hypertension is common in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who experience shortness of breath during exercise and reduced exercise capacity despite normalised pulmonary arterial pressure (PAP) at rest; however, the relationship between exercise pulmonary hypertension and exercise capacity remains unclear. Here we aimed to determine whether exercise pulmonary hypertension is related to exercise capacity and ventilatory efficiency in CTEPH patients with normalised resting haemodynamics after pulmonary balloon angioplasty (BPA). PATIENTS AND METHODS In total, 249 patients with CTEPH treated with BPA (mean±sd age 63±14 years; male:female 62:187) with normal mean PAP (mPAP) (<25 mmHg) and pulmonary arterial wedge pressure (≤15 mmHg) at rest underwent cardiopulmonary exercise testing with right heart catheterisation. mPAP-cardiac output (CO) during exercise was plotted using multipoint plots. Exercise pulmonary hypertension was defined by a mPAP-CO slope >3.0. RESULTS At rest, pulmonary vascular resistance was significantly higher in the exercise pulmonary hypertension group (n=116) than in the non-exercise pulmonary hypertension group (n=133). Lower peak oxygen consumption (13.5±3.8 versus 16.6±4.7 mL·min-1·kg-1; p<0.001) was observed in the former group. The mPAP-CO slope was negatively correlated with peak oxygen consumption (r= -0.45, p<0.001) and positively correlated with the minute ventilation versus carbon dioxide output slope (r=0.39, p<0.001). CONCLUSIONS Impaired exercise capacity and ventilatory efficiency were observed in patients with CTEPH who had normalised PAP at rest but exercise pulmonary hypertension.
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Affiliation(s)
- Hanako Kikuchi
- Dept of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Ayumi Goda
- Dept of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Kaori Takeuchi
- Dept of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Takumi Inami
- Dept of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Takashi Kohno
- Dept of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Konomi Sakata
- Dept of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Kyoko Soejima
- Dept of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Toru Satoh
- Dept of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
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129
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Serra W, Placci A, Rossi C, Cecchini S. Patent ductus venosus and exercise related pulmonary hypertension: a case of a young adult with successful surgery closure. JOURNAL OF CONGENITAL CARDIOLOGY 2020. [DOI: 10.1186/s40949-020-00032-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
The patent ductus venosus is an embryological portosystemic shunt that connects the umbilical vein to the inferior vena cava and it can be diagnosed incidentally or in subjects suffering from hepatic encephalopathy, hypoxemia or hypoglycaemia. Sometimes it can be found in patients with cardiac defects or hypoxia caused by pulmonary arteriovenous shunting.
Case presentation
A 34-year-old male patient was referred to our medical centre for further evaluation of abdominal pain and moderate exertional dyspnoea. An exercise stress echocardiogram was performed in order to understand the mechanism of the exertional dyspnoea. The test was interrupted due to dyspnoea and desaturation and an estimated pulmonary pressure value of 65 mmHg was detected. Exercise pulmonary hypertension (PH) seems to represent the hemodynamic manifestation of early pulmonary vascular disease, acting as a possible transitional phase anticipating resting PH.
An MRI of the abdomen showed the presence of a portosystemic shunt from a patent ductus venosus, associated with stenosis of the celiac tripod artery. A CT scan, of the pulmonary circulation, showed a normal pulmonary venous return,mediastinal vessel a normal pulmonary artery. Subsequently, taking into consideration the large size (> 25 mm) of the duct, treatment (closure) of the patent ductus venosus with the help of a detachable vascular plug device was not feasible and open surgery rather than a percutaneous invasive approach would be advisable.
Conclusion
Persistent ductus venous can lead to pulmonary arteriovenous shunt fistula and exercise related pulmonary hypertension. Percutaneous or surgical closure requires detailed planning and an anatomical and physiological evaluations.
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130
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Caravita S, Baratto C, Perego GB, Cecchi F, Crotti L, Parati G. Invasive Hemodynamics of Hypertrophic Cardiomyopathy: Exercise Versus Isoproterenol. Circ Heart Fail 2020; 13:e007000. [PMID: 32482090 DOI: 10.1161/circheartfailure.120.007000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sergio Caravita
- Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy (S.C., C.B., G.B.P., F.C., L.C., G.P.).,Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy (S.C.)
| | - Claudia Baratto
- Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy (S.C., C.B., G.B.P., F.C., L.C., G.P.).,Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy (C.B., L.C., G.P.)
| | - Giovanni Battista Perego
- Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy (S.C., C.B., G.B.P., F.C., L.C., G.P.)
| | - Franco Cecchi
- Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy (S.C., C.B., G.B.P., F.C., L.C., G.P.)
| | - Lia Crotti
- Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy (S.C., C.B., G.B.P., F.C., L.C., G.P.).,Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy (C.B., L.C., G.P.)
| | - Gianfranco Parati
- Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy (S.C., C.B., G.B.P., F.C., L.C., G.P.).,Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy (C.B., L.C., G.P.)
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131
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Bonno EL, Viray MC, Jackson GR, Houston BA, Tedford RJ. Modern Right Heart Catheterization: Beyond Simple Hemodynamics. ACTA ACUST UNITED AC 2020. [DOI: 10.21693/1933-088x-19.1.6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Eric L. Bonno
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Michael C. Viray
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Gregory R. Jackson
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Brian A. Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
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132
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Jain CC, Borlaug BA. Performance and Interpretation of Invasive Hemodynamic Exercise Testing. Chest 2020; 158:2119-2129. [PMID: 32473950 DOI: 10.1016/j.chest.2020.05.552] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/15/2020] [Accepted: 05/22/2020] [Indexed: 01/06/2023] Open
Abstract
Exertional dyspnea is a common complaint for patients seen in pulmonary, cardiac, and general medicine clinics, and elucidating the cause is often challenging, particularly when physical examination, echocardiography, radiography, and pulmonary function test results are inconclusive. Invasive cardiopulmonary exercise testing has emerged as the gold standard test to define causes of dyspnea and exertional limitation in this population. In this review, we describe the methods for performing and interpreting invasive cardiopulmonary exercise testing, with particular attention to the hemodynamic and blood sampling data as they apply to patients being evaluated for heart failure and pulmonary hypertension.
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133
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Neder JA, Berton DC, O'Donnell DE. The Lung Function Laboratory to Assist Clinical Decision-making in Pulmonology: Evolving Challenges to an Old Issue. Chest 2020; 158:1629-1643. [PMID: 32428514 DOI: 10.1016/j.chest.2020.04.064] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/21/2020] [Accepted: 04/26/2020] [Indexed: 12/17/2022] Open
Abstract
The lung function laboratory frequently provides relevant information to the practice of pulmonology. Clinical interpretation of pulmonary function and exercise tests, however, has been complicated more recently by temporal changes in demographic characteristics (higher life expectancy), anthropometric attributes (increased obesity prevalence), and the surge of polypharmacy in a sedentary population with multiple chronic degenerative diseases. In this narrative review, we concisely discuss some key challenges to test interpretation that have been affected by these epidemiologic shifts: (a) the confounding effects of advanced age and severe obesity, (b) the contemporary controversies in the diagnosis of obstruction (including asthma and/or COPD), (c) the importance of considering the diffusing capacity of the lung for carbon monoxide (Dlco)/"accessible" alveolar volume (carbon monoxide transfer coefficient) in association with Dlco to uncover the causes of impaired gas exchange, and (d) the modern role of the pulmonary function laboratory (including cardiopulmonary exercise testing) in the investigation of undetermined dyspnea. Following a Bayesian perspective, we suggest interpretative algorithms that consider the pretest probability of abnormalities as indicated by additional clinical information. We, therefore, adopt a pragmatic approach to help the practicing pulmonologist to apply the information provided by the lung function laboratory to the care of individual patients.
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Affiliation(s)
- J Alberto Neder
- Pulmonary Function Laboratory and Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Kingston Health Science Center, Queen's University, Kingston, ON, Canada.
| | - Danilo C Berton
- Division of Respirology, Department of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Denis E O'Donnell
- Pulmonary Function Laboratory and Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Kingston Health Science Center, Queen's University, Kingston, ON, Canada
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134
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135
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Does PAP/CO Ratio Have a Linear Relationship? J Am Coll Cardiol 2020; 75:2646. [DOI: 10.1016/j.jacc.2020.02.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 02/10/2020] [Indexed: 11/23/2022]
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136
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Ramírez P, Otero R, Barberà JA. Pulmonary chronic thromboembolic disease. Arch Bronconeumol 2020; 56:314-321. [PMID: 35373741 DOI: 10.1016/j.arbr.2020.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 10/21/2019] [Indexed: 06/14/2023]
Abstract
Persistent thrombotic lesions are common in patients with pulmonary embolism. These lesions occur on a clinical spectrum, ranging from an asymptomatic course with complete functional recovery to chronic thromboembolic pulmonary hypertension. The concept of chronic thromboembolic disease has emerged in recent years to describe a subgroup of patients with persistent thrombotic lesions who have symptoms on exertion and pulmonary vascular dysfunction, but no pulmonary hypertension at rest. The prevalence of this entity is unknown and the criteria for diagnosing it are not defined. The aim of this article is to analyze post-pulmonary embolism sequelae and review existing evidence on chronic thromboembolic disease, with special emphasis on its diagnosis and therapeutic approach.
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Affiliation(s)
- Purificación Ramírez
- Servicio de Neumología, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | - Remedios Otero
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío-Instituto de Biomedicina de Sevilla (IBiS); CSIC; Universidad de Sevilla, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Joan Albert Barberà
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Servicio de Neumología y Alergia Respiratoria, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); Universidad de Barcelona, Barcelona, Spain.
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137
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França EET, Gomes JPV, De Lira JMB, Amaral TCN, Vilaça AF, Paiva Júnior MDS, Elihimas Júnior UF, Correia Júnior MAV, Forgiarini Júnior LA, Costa MJC, Andrade MA, Ribeiro LC, De Castro CMMB. Acute effect of passive cycle-ergometry and functional electrical stimulation on nitrosative stress and inflammatory cytokines in mechanically ventilated critically ill patients: a randomized controlled trial. ACTA ACUST UNITED AC 2020; 53:e8770. [PMID: 32294698 PMCID: PMC7162584 DOI: 10.1590/1414-431x20208770] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 01/06/2020] [Indexed: 11/22/2022]
Abstract
Early mobilization is beneficial for critically ill patients because it reduces muscle weakness acquired in intensive care units. The objective of this study was to assess the effect of functional electrical stimulation (FES) and passive cycle ergometry (PCE) on the nitrous stress and inflammatory cytometry in critically ill patients. This was a controlled, randomized, open clinical trial carried out in a 16-bed intensive care unit. The patients were randomized into four groups: Control group (n=10), did not undergo any therapeutic intervention during the study; PCE group (n=9), lower-limb PCE for 30 cycles/min for 20 min; FES group (n=9), electrical stimulation of quadriceps muscle for 20 min; and FES with PCE group (n=7), patients underwent PCE and FES, with their order determined randomly. The serum levels of nitric oxide, tumor necrosis factor alpha, interferon gamma, and interleukins 6 and 10 were analyzed before and after the intervention. There were no differences in clinical or demographic characteristics between the groups. The results revealed reduced nitric oxide concentrations one hour after using PCE (P<0.001) and FES (P<0.05), thereby indicating that these therapies may reduce cellular nitrosative stress when applied separately. Tumor necrosis factor alpha levels were reduced after the PCE intervention (P=0.049). PCE and FES reduced nitric oxide levels, demonstrating beneficial effects on the reduction of nitrosative stress. PCE was the only treatment that reduced the tumor necrosis factor alpha concentration.
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Affiliation(s)
- E E T França
- Departamento de Fisioterapia e Programa de Pós-graduação em Fisioterapia, Universidade Federal da Paraíba, João Pessoa, PB, Brasil
| | - J P V Gomes
- Unidade de Terapia Intensiva, Hospital Agamenon Magalhães, Recife, PE, Brasil
| | - J M B De Lira
- Programa de Residência de Clínica Médica, Hospital Otávio de Freitas, Recife, PE, Brasil
| | - T C N Amaral
- Unidade de Terapia Intensiva, Hospital Agamenon Magalhães, Recife, PE, Brasil
| | - A F Vilaça
- Unidade de Terapia Intensiva, Hospital Agamenon Magalhães, Recife, PE, Brasil
| | - M D S Paiva Júnior
- Unidade de Terapia Intensiva, Hospital Agamenon Magalhães, Recife, PE, Brasil
| | - U F Elihimas Júnior
- Unidade de Terapia Intensiva, Hospital Agamenon Magalhães, Recife, PE, Brasil
| | - M A V Correia Júnior
- Programa de Pós-graduação em Educação Física e Hebiatria, Universidade de Pernambuco, Recife, PE, Brasil
| | - L A Forgiarini Júnior
- Departamento de Fisioterapia e Programa de Pós-graduação em Saúde e Desenvolvimento Humano, Universidade La Salle, Canoas, RS, Brasil
| | - M J C Costa
- Departamento de Fisioterapia, Universidade Federal de Pernambuco, Recife, PE, Brasil
| | - M A Andrade
- Departamento de Fisioterapia, Universidade Federal de Pernambuco, Recife, PE, Brasil
| | - L C Ribeiro
- Unidade de Terapia Intensiva, Hospital Agamenon Magalhães, Recife, PE, Brasil
| | - C M M B De Castro
- Departamento de Fisioterapia e Medicina Tropical, Universidade Federal de Pernambuco, Recife, PE, Brasil
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Baratto C, Caravita S, Perego GB, Parati G. Stiff left atrial syndrome after low-dose radiotherapy for right breast cancer: The need for invasive hemodynamics at exercise. Catheter Cardiovasc Interv 2020; 95:1059-1061. [PMID: 31194281 DOI: 10.1002/ccd.28348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/26/2019] [Accepted: 05/16/2019] [Indexed: 11/11/2022]
Abstract
Stiff left atrial (LA) syndrome is a distinct phenotype of heart failure with preserved ejection fraction, characterized by predominant high LA pressure. We describe the case of a middle-aged woman who developed exertional breathlessness during low-dose radiotherapy for right breast cancer and who was eventually found to be affected by stiff LA syndrome. Invasive hemodynamics allowed the recognition of pathognomonic tall V waves in the wedge position during exercise, in spite of inconclusive noninvasive investigations.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Giovanni B Perego
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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139
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Gredic M, Blanco I, Kovacs G, Helyes Z, Ferdinandy P, Olschewski H, Barberà JA, Weissmann N. Pulmonary hypertension in chronic obstructive pulmonary disease. Br J Pharmacol 2020; 178:132-151. [PMID: 31976545 DOI: 10.1111/bph.14979] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 12/29/2019] [Accepted: 01/06/2020] [Indexed: 12/12/2022] Open
Abstract
Even mild pulmonary hypertension (PH) is associated with increased mortality and morbidity in patients with chronic obstructive pulmonary disease (COPD). However, the underlying mechanisms remain elusive; therefore, specific and efficient treatment options are not available. Therapeutic approaches tested in the clinical setting, including long-term oxygen administration and systemic vasodilators, gave disappointing results and might be only beneficial for specific subgroups of patients. Preclinical studies identified several therapeutic approaches for the treatment of PH in COPD. Further research should provide deeper insight into the complex pathophysiological mechanisms driving vascular alterations in COPD, especially as such vascular (molecular) alterations have been previously suggested to affect COPD development. This review summarizes the current understanding of the pathophysiology of PH in COPD and gives an overview of the available treatment options and recent advances in preclinical studies. LINKED ARTICLES: This article is part of a themed issue on Risk factors, comorbidities, and comedications in cardioprotection. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.1/issuetoc.
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Affiliation(s)
- Marija Gredic
- Cardio-Pulmonary Institute, University of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University, Giessen, Germany
| | - Isabel Blanco
- Department of Pulmonary Medicine, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
| | - Gabor Kovacs
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Zsuzsanna Helyes
- Department of Pharmacology and Pharmacotherapy, Medical School & János Szentágothai Research Centre, University of Pécs, Pécs, Hungary.,PharmInVivo Ltd, Pécs, Hungary
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary.,Pharmahungary Group, Szeged, Hungary
| | - Horst Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Joan Albert Barberà
- Department of Pulmonary Medicine, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
| | - Norbert Weissmann
- Cardio-Pulmonary Institute, University of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig-University, Giessen, Germany
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140
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Kohli P, Kelly VJ, Kehl EG, Rodriguez-Lopez J, Hibbert KA, Kone M, Systrom DM, Waxman AB, Venegas JG, Channick R, Winkler T, Harris RS. Perfusion Imaging Distinguishes Exercise Pulmonary Arterial Hypertension at Rest. Am J Respir Crit Care Med 2020; 199:1438-1441. [PMID: 30811948 DOI: 10.1164/rccm.201810-1899le] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Puja Kohli
- 1 Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | | | - Ekaterina G Kehl
- 1 Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | | | - Kathryn A Hibbert
- 1 Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | - Mamary Kone
- 1 Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | - David M Systrom
- 3 Brigham and Women's Hospital and Harvard Medical School Boston, Massachusetts
| | - Aaron B Waxman
- 3 Brigham and Women's Hospital and Harvard Medical School Boston, Massachusetts
| | - Jose G Venegas
- 1 Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | - Richard Channick
- 1 Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | - Tilo Winkler
- 1 Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | - R Scott Harris
- 1 Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
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141
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Obokata M, Kane GC, Sorimachi H, Reddy YNV, Olson TP, Egbe AC, Melenovsky V, Borlaug BA. Noninvasive evaluation of pulmonary artery pressure during exercise: the importance of right atrial hypertension. Eur Respir J 2020; 55:13993003.01617-2019. [PMID: 31771997 DOI: 10.1183/13993003.01617-2019] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/02/2019] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Identification of elevated pulmonary artery pressures during exercise has important diagnostic, prognostic and therapeutic implications. Stress echocardiography is frequently used to estimate pulmonary artery pressures during exercise testing, but data supporting this practice are limited. This study examined the accuracy of Doppler echocardiography for the estimation of pulmonary artery pressures at rest and during exercise. METHODS Simultaneous cardiac catheterisation-echocardiographic studies were performed at rest and during exercise in 97 subjects with dyspnoea. Echocardiography-estimated pulmonary artery systolic pressure (ePASP) was calculated from the right ventricular (RV) to right atrial (RA) pressure gradient and estimated RA pressure (eRAP), and then compared with directly measured PASP and RAP. RESULTS Estimated PASP was obtainable in 57% of subjects at rest, but feasibility decreased to 15-16% during exercise, due mainly to an inability to obtain eRAP during stress. Estimated PASP correlated well with direct PASP at rest (r=0.76, p<0.0001; bias -1 mmHg) and during exercise (r=0.76, p=0.001; bias +3 mmHg). When assuming eRAP of 10 mmHg, ePASP correlated with direct PASP (r=0.70, p<0.0001), but substantially underestimated true values (bias +9 mmHg), with the greatest underestimation among patients with severe exercise-induced pulmonary hypertension (EIPH). Estimation of eRAP during exercise from resting eRAP improved discrimination of patients with or without EIPH (area under the curve 0.81), with minimal bias (5 mmHg), but wide limits of agreement (-14-25 mmHg). CONCLUSIONS The RV-RA pressure gradient can be estimated with reasonable accuracy during exercise when measurable. However, RA hypertension frequently develops in patients with EIPH, and the inability to noninvasively account for this leads to substantial underestimation of exercise pulmonary artery pressures.
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Affiliation(s)
- Masaru Obokata
- Dept of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Garvan C Kane
- Dept of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hidemi Sorimachi
- Dept of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yogesh N V Reddy
- Dept of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Thomas P Olson
- Dept of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alexander C Egbe
- Dept of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Vojtech Melenovsky
- Institute for Clinical and Experimental Medicine - IKEM, Prague, Czech Republic
| | - Barry A Borlaug
- Dept of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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142
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Moss N, Rakita V, Lala A, Parikh A, Roldan J, Mitter SS, Anyanwu A, Campoli M, Burkhoff D, Mancini DM. Hemodynamic Response to Exercise in Patients Supported by Continuous Flow Left Ventricular Assist Devices. JACC-HEART FAILURE 2020; 8:291-301. [PMID: 32035893 DOI: 10.1016/j.jchf.2019.10.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/09/2019] [Accepted: 10/10/2019] [Indexed: 02/09/2023]
Abstract
OBJECTIVES This study sought to characterize the hemodynamic response to exercise in LVAD-supported patients and identify parameters most strongly associated with peak oxygen consumption (VO2). BACKGROUND Despite improved survival for heart failure patients afforded by continuous flow left ventricular assist devices (LVADs), peak exercise capacity remains impaired. Mechanisms underlying this reduced functional capacity remain poorly understood. METHODS Patients referred for post-VAD hemodynamic optimization from December 2017 through June 2019 were enrolled. Swan Ganz catheters were inserted and upright incremental bicycle ergometry with respiratory gas analysis was performed. Hemodynamic measurements, mixed venous saturation, and arterial blood pressure were recorded every 3 min during exercise. Linear correlations were performed between peak VO2 (ml/min) and peak Fick cardiac output (CO), peak device flow, the assumed intrinsic CO derived as Fick CO-device flow, peak pressure differential across the LVAD (mean arterial pressure-pulmonary capillary wedge pressure), peak pressure differential across right ventricle (mean pulmonary artery pressure - right atrial pressure) and systemic vascular resistance. RESULTS Forty-five patients supported by axial flow pumps (n = 12) and centrifugal flow pumps (n = 33) were studied. There were 34 men and 11 women. Age averaged 60 ± 10 years. Peak VO2 averaged 10.6 ± 3.1 ml/kg/min. Fick CO had the greatest correlation with peak VO2 with r = 0.73 (p < 0.0001) followed by intrinsic CO (r = 0.67; p < 0.0001). Multivariate model that best predicted peak VO2 included Fick CO and peak arterial venous oxygen (AVO2) difference. CONCLUSIONS LVAD supported patients have severely impaired peak exercise capacity. The peak Fick cardiac output was the best correlate of peak exercise performance.
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Affiliation(s)
- Noah Moss
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Val Rakita
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anuradha Lala
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Aditya Parikh
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Julie Roldan
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sumeet S Mitter
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anelechi Anyanwu
- Division of Cardiothoracic Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michelle Campoli
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dan Burkhoff
- Cardiovascular Research Foundation, New York, New York
| | - Donna M Mancini
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.
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143
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Riou M, Pizzimenti M, Enache I, Charloux A, Canuet M, Andres E, Talha S, Meyer A, Geny B. Skeletal and Respiratory Muscle Dysfunctions in Pulmonary Arterial Hypertension. J Clin Med 2020; 9:jcm9020410. [PMID: 32028638 PMCID: PMC7073630 DOI: 10.3390/jcm9020410] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 01/20/2020] [Accepted: 01/28/2020] [Indexed: 12/18/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease, which leads to the progressive loss and remodeling of the pulmonary vessels, right heart failure, and death. Different clinical presentations can be responsible for such a bad prognosis disease and the underlying mechanisms still need to be further examined. Importantly, skeletal and respiratory muscle abnormalities largely contribute to the decreased quality of life and exercise intolerance observed in patients with PAH. At the systemic level, impaired oxygen supply through reduced cardiac output and respiratory muscle dysfunctions, which potentially result in hypoxemia, is associated with altered muscles vascularization, inflammation, enhanced catabolic pathways, and impaired oxygen use through mitochondrial dysfunctions that are likely participate in PAH-related myopathy. Sharing new insights into the pathological mechanisms of PAH might help stimulate specific research areas, improving the treatment and quality of life of PAH patients. Indeed, many of these muscular impairments are reversible, strongly supporting the development of effective preventive and/or therapeutic approaches, including mitochondrial protection and exercise training.
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Affiliation(s)
- Marianne Riou
- Unistra, Translational Medicine Federation of Strasbourg (FMTS), Faculty of Medicine, Team 3072 “Mitochondria, Oxidative Stress and Muscle Protection”, 11 rue Humann, 67000 Strasbourg, France
- Physiology and Functional Exploration Service, University Hospital of Strasbourg, 1 Place de l’Hôpital, 67091 Strasbourg CEDEX, France
- Pulmonology Service, University Hospital of Strasbourg, 1 place de l’Hôpital, 67091 Strasbourg CEDEX, France
| | - Mégane Pizzimenti
- Unistra, Translational Medicine Federation of Strasbourg (FMTS), Faculty of Medicine, Team 3072 “Mitochondria, Oxidative Stress and Muscle Protection”, 11 rue Humann, 67000 Strasbourg, France
- Physiology and Functional Exploration Service, University Hospital of Strasbourg, 1 Place de l’Hôpital, 67091 Strasbourg CEDEX, France
| | - Irina Enache
- Unistra, Translational Medicine Federation of Strasbourg (FMTS), Faculty of Medicine, Team 3072 “Mitochondria, Oxidative Stress and Muscle Protection”, 11 rue Humann, 67000 Strasbourg, France
- Physiology and Functional Exploration Service, University Hospital of Strasbourg, 1 Place de l’Hôpital, 67091 Strasbourg CEDEX, France
| | - Anne Charloux
- Unistra, Translational Medicine Federation of Strasbourg (FMTS), Faculty of Medicine, Team 3072 “Mitochondria, Oxidative Stress and Muscle Protection”, 11 rue Humann, 67000 Strasbourg, France
- Physiology and Functional Exploration Service, University Hospital of Strasbourg, 1 Place de l’Hôpital, 67091 Strasbourg CEDEX, France
| | - Mathieu Canuet
- Pulmonology Service, University Hospital of Strasbourg, 1 place de l’Hôpital, 67091 Strasbourg CEDEX, France
| | - Emmanuel Andres
- Internal Medicine, Diabete and Metabolic Diseases Service, University Hospital of Strasbourg, 1 place de l’Hôpital, 67091 Strasbourg CEDEX, France;
| | - Samy Talha
- Unistra, Translational Medicine Federation of Strasbourg (FMTS), Faculty of Medicine, Team 3072 “Mitochondria, Oxidative Stress and Muscle Protection”, 11 rue Humann, 67000 Strasbourg, France
- Physiology and Functional Exploration Service, University Hospital of Strasbourg, 1 Place de l’Hôpital, 67091 Strasbourg CEDEX, France
| | - Alain Meyer
- Unistra, Translational Medicine Federation of Strasbourg (FMTS), Faculty of Medicine, Team 3072 “Mitochondria, Oxidative Stress and Muscle Protection”, 11 rue Humann, 67000 Strasbourg, France
- Physiology and Functional Exploration Service, University Hospital of Strasbourg, 1 Place de l’Hôpital, 67091 Strasbourg CEDEX, France
| | - Bernard Geny
- Unistra, Translational Medicine Federation of Strasbourg (FMTS), Faculty of Medicine, Team 3072 “Mitochondria, Oxidative Stress and Muscle Protection”, 11 rue Humann, 67000 Strasbourg, France
- Physiology and Functional Exploration Service, University Hospital of Strasbourg, 1 Place de l’Hôpital, 67091 Strasbourg CEDEX, France
- Correspondence:
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144
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Ho JE, Zern EK, Lau ES, Wooster L, Bailey CS, Cunningham T, Eisman AS, Hardin KM, Farrell R, Sbarbaro JA, Schoenike MW, Houstis NE, Baggish AL, Shah RV, Nayor M, Malhotra R, Lewis GD. Exercise Pulmonary Hypertension Predicts Clinical Outcomes in Patients With Dyspnea on Effort. J Am Coll Cardiol 2020; 75:17-26. [PMID: 31918830 PMCID: PMC7043927 DOI: 10.1016/j.jacc.2019.10.048] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/08/2019] [Accepted: 10/22/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Abnormal pulmonary arterial pressure (PAP) responses to exercise have been described in select individuals; however, clinical and prognostic implications of exercise pulmonary hypertension (exPH) among broader samples remains unclear. OBJECTIVES This study sought to investigate the association of exPH with clinical determinants and outcomes. METHODS The authors studied individuals with chronic exertional dyspnea and preserved ejection fraction who underwent cardiopulmonary exercise testing with invasive hemodynamic monitoring. Exercise pulmonary hypertension was ascertained using minute-by-minute PAP and cardiac output (CO) measurements to calculate a PAP/CO slope, and exPH defined as a PAP/CO slope >3 mm Hg/l/min. The primary outcome was cardiovascular (CV) hospitalization or all-cause mortality. RESULTS Among 714 individuals (age 57 years, 59% women), 296 (41%) had abnormal PAP/CO slopes. Over a mean follow-up of 3.7 ± 2.9 years, there were 208 CV or death events. Individuals with abnormal PAP/CO slope had a 2-fold increased hazard of future CV or death event (multivariable-adjusted hazard ratio: 2.03; 95% confidence interval: 1.48 to 2.78; p < 0.001). The association of abnormal PAP/CO slope with outcomes remained significant after excluding rest PH (n = 146, hazard ratio: 1.75; 95% confidence interval: 1.21 to 2.54; p = 0.003). Both pre- and post-capillary contributions to exPH independently predicted adverse events (p < 0.001 for both). CONCLUSIONS Exercise pulmonary hypertension is independently associated with CV event-free survival among individuals undergoing evaluation of chronic dyspnea. These findings suggest incremental value of exercise hemodynamic assessment to resting measurements alone in characterizing the burden of PH in individuals with dyspnea. Whether PH and PH subtypes unmasked by exercise can be used to guide targeted therapeutic interventions requires further investigation.
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Affiliation(s)
- Jennifer E Ho
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts; Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
| | - Emily K Zern
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily S Lau
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Luke Wooster
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Cole S Bailey
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas Cunningham
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Aaron S Eisman
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kathryn M Hardin
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Robyn Farrell
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - John A Sbarbaro
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Mark W Schoenike
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Nicholas E Houstis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Aaron L Baggish
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Ravi V Shah
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Matthew Nayor
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rajeev Malhotra
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts; Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Gregory D Lewis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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145
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Hoeper MM. Exercise Pulmonary Hypertension Is Back. J Am Coll Cardiol 2020; 75:27-28. [DOI: 10.1016/j.jacc.2019.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 11/10/2019] [Indexed: 10/25/2022]
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146
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Zou RH, Wallace WD, Nouraie SM, Chan SY, Risbano MG. Lower DLco% identifies exercise pulmonary hypertension in patients with parenchymal lung disease referred for dyspnea. Pulm Circ 2020; 10:2045894019891912. [PMID: 32128158 PMCID: PMC7031800 DOI: 10.1177/2045894019891912] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 11/11/2019] [Indexed: 01/13/2023] Open
Abstract
Exercise pulmonary hypertension is an underappreciated form of physical limitation related to early pulmonary vascular disease. A low diffusing capacity of lungs for carbon monoxide (DLco) can be seen in patients with resting pulmonary hypertension as well as parenchymal lung disease. It remains unclear whether low DLco% identifies early pulmonary vascular disease. We hypothesize that a reduced DLco% differentiates the presence of exercise pulmonary hypertension in patients with parenchymal lung disease. Fifty-six patients referred for unexplained exertional dyspnea with pulmonary function tests within six months of hemodynamic testing underwent exercise right heart catheterization. Exclusion criteria included resting pulmonary arterial or venous hypertension. Receiver operator characteristic curve determined the optimal DLco% cutoffs based on the presence or absence of parenchymal lung disease. Twenty-one (37%) patients had parenchymal lung disease, most common manifesting as chronic obstructive lung disease or interstitial lung disease. In patients with parenchymal lung disease, a DLco of 46% demonstrated 100% sensitivity and 73% specificity for detecting exercise pulmonary hypertension. In patients without parenchymal lung disease, a DLco of 73% demonstrated 58% sensitivity and 94% specificity for detecting exercise pulmonary hypertension. In both cohorts, DLco% below the optimum cutoffs were associated with higher peak mean pulmonary arterial pressure and peak total pulmonary resistance consistent with the hemodynamic definition of exercise pulmonary hypertension. Patients with a DLco < 46% were more often treated with pulmonary vasodilators and had a trend to higher mortality and lung transplant. DLco% is a simple non-invasive screening test for the presence of exercise pulmonary hypertension in our mixed referral population with progressive exertional dyspnea. DLco < 46% with parenchymal lung disease and DLco < 73% without parenchymal lung disease may play a role in differentiating the presence of pulmonary vascular disease prior to invasive hemodynamic testing.
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Affiliation(s)
- Richard H. Zou
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - William D. Wallace
- Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, USA
| | - S. Mehdi Nouraie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stephen Y. Chan
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael G. Risbano
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Boucly A, Morélot-Panzini C, Garcia G, Weatherald J, Jaïs X, Savale L, Montani D, Humbert M, Similowski T, Sitbon O, Laveneziana P. Intensity and quality of exertional dyspnoea in patients with stable pulmonary hypertension. Eur Respir J 2019; 55:13993003.02108-2018. [DOI: 10.1183/13993003.02108-2018] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 10/28/2019] [Indexed: 11/05/2022]
Abstract
Dynamic hyperinflation is observed during exercise in 60% of patients with clinically stable pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH), intensifying exertional dyspnoea. The impact of dynamic changes in respiratory mechanics during exercise on qualitative dimensions of dyspnoea in these patients has not been evaluated.26 patients (PAH n=17; CTEPH n=9) performed an incremental symptom-limited cycle exercise test. Minute ventilation (V′E), breathing pattern, operating lung volumes and dyspnoea intensity were assessed throughout exercise. Dyspnoea quality was serially assessed during exercise using a three-item questionnaire (dyspnoea descriptors). The inflection point of tidal volume (VT) relative to V′E was determined for each incremental test. Changes in inspiratory capacity during exercise defined two groups of patients: hyperinflators (65%) and non-hyperinflators (35%). Multidimensional characterisation of dyspnoea was performed after exercise using the Multidimensional Dyspnea Profile.In hyperinflators, inspiratory capacity decreased progressively throughout exercise by 0.36 L, while remaining stable in non-hyperinflators. The “work/effort” descriptor was most frequently selected throughout exercise in both types of patients (65% of all responses). At the VT/V′E inflection, work/effort plateaued while “unsatisfied inspiration” descriptors became selected predominantly only in hyperinflators (77% of all responses). In the affective domain, the emotion most frequently associated with dyspnoea was anxiety.In pulmonary hypertension patients who develop hyperinflation during exercise, dyspnoea descriptors referring to unsatisfied inspiration become predominant following the VT/V′E inflection. As these descriptors are generally associated with more negative emotional experiences, delaying or preventing the VT/V′E inflection may have important implications for symptom management in patients with pulmonary hypertension.
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Goda A, Takeuchi K, Kikuchi H, Finger M, Inami T, Sakata K, Soejima K, Satoh T. Etiology of Exercise-Induced Pulmonary Hypertension Can Be Differentiated by Echocardiography - Insight From Patients With Chronic Pulmonary Thromboembolism With Normal Resting Hemodynamics by Balloon Pulmonary Angioplasty. Circ J 2019; 83:2527-2536. [PMID: 31582639 DOI: 10.1253/circj.cj-19-0489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Exercise-induced pulmonary hypertension (PH) is often seen in chronic thromboembolic PH (CTEPH) patients with normalized resting hemodynamics, but it is difficult to differentiate precapillary PH as pulmonary vascular dysfunction and post-capillary PH from occult-left ventricular dysfunction (LVD). The aim of this study was to examine whether the exercise-induced elevation of pulmonary arterial wedge pressure (PAWP) can be predicted by the echocardiographic index at rest.Methods and Results:A total of 71 CTEPH patients (67±11 years old, male/female=15/56) treated by pulmonary angioplasty with near-normal pulmonary arterial pressure (PAP) and normal PAWP at rest underwent symptom-limited exercise test using supine cycle ergometer with right heart catheterization. Exercise-induced elevation in PAWP of >20 mmHg during exercise was defined as occult-LVD. Resting echocardiography was performed within 3 months. In the occult-LVD (n=28), PAWP at rest after leg raising for exercise (14±4 vs. 11±3 mmHg, P<0.001), and mean PAP during exercise were higher compared with the non-LVD (n=43). Peak oxygen consumption, cardiac output, and pulmonary vascular resistance at peak exercise did not differ between groups. Left atrial volume index (LAVi) in the occult-LVD was significantly larger (39.7±8.1 vs. 34.4±9.6 mL/m2, P=0.017). LAVi correlated with exercise PAWP (r=0.356, P=0.002), but not resting PAWP (r=0.161, P=0.179). CONCLUSIONS Larger left atrial volume may reflect the exercise-induced PAWP elevation as occult-LVD in CTEPH patients.
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Affiliation(s)
- Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Kaori Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Hanako Kikuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Mayumi Finger
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Takumi Inami
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Konomi Sakata
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital
| | - Toru Satoh
- Department of Cardiovascular Medicine, Kyorin University Hospital
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149
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Quinn KA, Wappel SR, Kuru T, Steen VD. Exercise Echocardiography Predicts Future Development of Pulmonary Hypertension in a High-risk Cohort of Patients with Systemic Sclerosis. J Rheumatol 2019; 47:708-713. [DOI: 10.3899/jrheum.190226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2019] [Indexed: 01/05/2023]
Abstract
Objective.To evaluate whether a positive exercise echocardiogram (EE) predicts future development of pulmonary arterial hypertension (PAH) in a high-risk cohort of patients with systemic sclerosis (SSc).Methods.Patients with SSc with features associated with an increased risk for PAH were recruited into a prospective, observational cohort. All patients underwent clinical assessment and EE. A positive EE was defined as an increase of ≥ 20 mmHg in the right ventricular systolic pressure with exercise. All patients with positive EE underwent right heart catheterization (RHC).Results.The study included 85 patients. In the positive EE cohort, 10 of 43 patients (23%) developed resting pulmonary hypertension (PH) on RHC over a mean 4-year followup period [4 with PAH, 5 with pulmonary venous hypertension (PVH), and 1 with PH associated with interstitial lung disease]. In the persistently negative EE cohort, only 3 of 42 patients (7%) developed resting PH (1 PAH, 2 PVH; p = 0.04). Of the remaining 33 patients in the positive EE group who did not develop resting PH, 22 (67%) had a persistently positive EE over an average 5-year followup period.Conclusion.In this high-risk cohort of patients with SSc, a positive EE may predict the future development of resting PH. In addition, a majority of patients may have a persistently positive EE for years without progression to resting PH. Finally, a consistently negative EE may identify patients at low risk for future PH.
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150
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Pan Z, Marra AM, Benjamin N, Eichstaedt CA, Blank N, Bossone E, Cittadini A, Coghlan G, Denton CP, Distler O, Egenlauf B, Fischer C, Harutyunova S, Xanthouli P, Lorenz HM, Grünig E. Early treatment with ambrisentan of mildly elevated mean pulmonary arterial pressure associated with systemic sclerosis: a randomized, controlled, double-blind, parallel group study (EDITA study). Arthritis Res Ther 2019; 21:217. [PMID: 31655622 PMCID: PMC6815440 DOI: 10.1186/s13075-019-1981-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/16/2019] [Indexed: 02/07/2023] Open
Abstract
Objective The objective of this randomized, placebo-controlled, double-blind, parallel group, trial was to assess the effect of ambrisentan on mean pulmonary arterial pressure (mPAP) in patients with systemic sclerosis (SSc) and mildly elevated pulmonary hypertension (PH). Methods Thirty-eight SSc patients with mildly elevated mPAP at rest between 21 and 24 mmHg and/or > 30 mmHg during low-dose exercise were randomly assigned to treatment with either ambrisentan 5–10 mg/day or placebo. Right heart catheterization and further clinical parameters were assessed at baseline and after 6 months. The primary endpoint was the difference of mPAP change at rest between groups. Results After 6 months, the two groups did not differ in the primary endpoint (ambrisentan mPAP − 1 ± 6.4 mmHg vs. placebo − 0.73 ± 3.59 mmHg at rest, p = 0.884). However, three patients from the placebo group but none of the ambrisentan group progressed to SSc-associated pulmonary arterial hypertension. Furthermore, ambrisentan treatment showed significant improvements in the secondary endpoints cardiac index (CI) and pulmonary vascular resistance (PVR) at rest (CI 0.36 ± 0.66 l/min/m2 vs. − 0.31 ± 0.71 l/min/m2, p = 0.010; PVR − 0.70 ± 0.78 WU vs. 0.01 ± 0.71 WU, p = 0.012) and during exercise (CI 0.7 ± 0.81 l/min/m2 vs. − 0.45 ± 1.36 l/min/m2, p = 0.015; PVR − 0.84 ± 0.48 WU vs. − 0.0032 ± 0.34 WU, p < 0.0001). Conclusion This is the first randomized, double-blind, placebo-controlled study testing the effect of ambrisentan in patients with mildly elevated mPAP and/or exercise PH. The primary endpoint change in mPAP did only tendentially improve in the ambrisentan group, but the significant improvement of other hemodynamic parameters points to a possible benefit of ambrisentan and will be helpful to design future trials. Trial registration www.ClinicalTrials.gov, unique identifier NCT: NCT02290613, registered 14th of November 2014.
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Affiliation(s)
- Zixuan Pan
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | | | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christina A Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,Department of Human Genetics, University of Heidelberg, Heidelberg, Germany
| | - Norbert Blank
- Department of Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Eduardo Bossone
- Division of Cardiology, U.O.C. Rehabilitazione Cardiovascolare, A Cardarelli, Naples, Italy
| | - Antonio Cittadini
- Department of Translational Medical Sciences, University Federico II of Naples, Naples, Italy
| | - Gerry Coghlan
- Cardiology Department, Royal Free Hospital, London, UK
| | | | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christine Fischer
- Department of Human Genetics, University of Heidelberg, Heidelberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | | | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstraße 1, 69126, Heidelberg, Germany. .,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.
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