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Kutalek SP, Gupta A. Can Rapid Atrial Pacing Mimic Exercise in Diagnosing Heart Failure With Preserved Ejection Fraction? Am J Cardiol 2024; 211:350-351. [PMID: 37866393 DOI: 10.1016/j.amjcard.2023.08.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 08/25/2023] [Indexed: 10/24/2023]
Affiliation(s)
- Steven P Kutalek
- Medicine (Cardiology), Drexel University, Philadelphia, Pennsylvania; Regional Electrophysiology Associates, St. Mary Medical Center, Trinity Health Mid Atlantic, Langhorne, Pennsylvania.
| | - Ashwani Gupta
- Regional Electrophysiology Associates, St. Mary Medical Center, Trinity Health Mid Atlantic, Langhorne, Pennsylvania
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Campain J, Giverts I, Schoenicke MW, Sbarbaro J, Griskowitz C, Minasian A, Prasad C, Lewis A, Shah RV, Malhotra R, Lewis GD. Characterization and Prognostic Implications of Respirophasic Variation in Invasive Hemodynamic Measurements at Rest and With Exercise. J Card Fail 2024:S1071-9164(24)00001-0. [PMID: 38184293 DOI: 10.1016/j.cardfail.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/10/2023] [Accepted: 12/05/2023] [Indexed: 01/08/2024]
Affiliation(s)
- Joseph Campain
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ilya Giverts
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark W Schoenicke
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John Sbarbaro
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Catharine Griskowitz
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alexandra Minasian
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cheshta Prasad
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew Lewis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ravi V Shah
- Cardiology Division, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Rajeev Malhotra
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gregory D Lewis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Baratto C, Caravita S, Vachiéry JL. Pulmonary Hypertension Associated with Left Heart Disease. Semin Respir Crit Care Med 2023; 44:810-825. [PMID: 37709283 DOI: 10.1055/s-0043-1772754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Pulmonary hypertension (PH) is a common complication of diseases affecting the left heart, mostly found in patients suffering from heart failure, with or without preserved left ventricular ejection fraction. Initially driven by a passive increase in left atrial pressure (postcapillary PH), several mechanisms may lead in a subset of patient to significant structural changes of the pulmonary vessels or a precapillary component. In addition, the right ventricle may be independently affected, which results in right ventricular to pulmonary artery uncoupling and right ventricular failure, all being associated with a worse outcome. The differential diagnosis of PH associated with left heart disease versus pulmonary arterial hypertension (PAH) is especially challenging in patients with cardiovascular comorbidities and/or heart failure with preserved ejection fraction (HFpEF). A stepwise approach to diagnosis is proposed, starting with a proper clinical multidimensional phenotyping to identify patients in whom hemodynamic confirmation is deemed necessary. Provocative testing (exercise testing, fluid loading, or simple leg raising) is useful in the cath laboratory to identify patients with abnormal response who are more likely to suffer from HFpEF. In contrast with group 1 PH, management of PH associated with left heart disease must focus on the treatment of the underlying condition. Some PAH-approved targets have been unsuccessfully tried in clinical studies in a heterogeneous group of patients, some even leading to an increase in adverse events. There is currently no approved therapy for PH associated with left heart disease.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Bergamo, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, HUB Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
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Caravita S, Baratto C, Filippo A, Soranna D, Dewachter C, Zambon A, Perego GB, Muraru D, Senni M, Badano LP, Parati G, Vachiéry JL, Fudim M. Shedding Light on Latent Pulmonary Vascular Disease in Heart Failure With Preserved Ejection Fraction. JACC. HEART FAILURE 2023; 11:1427-1438. [PMID: 37115127 DOI: 10.1016/j.jchf.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/27/2023] [Accepted: 03/03/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Among patients with heart failure with preserved ejection fraction (HFpEF), a distinct hemodynamic phenotype has been recently described, ie, latent pulmonary vascular disease (HFpEF-latentPVD), defined by exercise pulmonary vascular resistance (PVR) >1.74 WU. OBJECTIVES This study aims to explore the pathophysiological significance of HFpEF-latentPVD. METHODS The authors analyzed a cohort of patients who had undergone supine exercise right heart catheterization with cardiac output (CO) measured by direct Fick method, between 2016 and 2021. HFpEF-latentPVD patients were compared with HFpEF control patients. RESULTS Out of 86 HFpEF patients, 21% qualified as having HFpEF-latentPVD, 78% of whom had PVR >2 WU at rest. Patients with HFpEF-latentPVD were older, with a higher pretest probability of HFpEF, and more frequently experienced atrial fibrillation and at least moderate tricuspid regurgitation (P < 0.05). PVR trajectories differed between HFpEF-latentPVD patients and HFpEF control patients (Pinteraction = 0.008), slightly increasing in the former and reducing in the latter. HFpEF-latentPVD patients displayed more frequent hemodynamically significant tricuspid regurgitation during exercise (P = 0.002) and had more impaired CO and stroke volume reserve (P < 0.05). Exercise PVR was correlated with mixed venous O2 tension (R2 = 0.33) and stroke volume (R2 = 0.31) in HFpEF-latentPVD patients. The HFpEF-latentPVD patients had had higher dead space ventilation during exercise and higher PaCO2 (P < 0.05), which correlated with resting PVR (R2 = 0.21). Event-free survival was reduced in HFpEF-latentPVD patients (P < 0.05). CONCLUSIONS The results suggest that when CO is measured by direct Fick, few HFpEF patients have isolated latent PVD (ie, normal PVR at rest, becoming abnormal during exercise). HFpEF-latentPVD patients present with CO limitation to exercise, associated with dynamic tricuspid regurgitation, altered ventilatory control, and pulmonary vascular hyperreactivity, portending a poor prognosis.
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Affiliation(s)
- Sergio Caravita
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy; Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy
| | - Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy.
| | - Aurora Filippo
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Davide Soranna
- Biostatistic Unit, IRCCS Istituto Auxologico Italiano, Milano, Italy
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Antonella Zambon
- Biostatistic Unit, IRCCS Istituto Auxologico Italiano, Milano, Italy; Department of Statistics and Quantitative Methods, Università di Milano-Bicocca, Milano, Italy
| | | | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Michele Senni
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy; Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Caravita S, Baratto C, Fudim M. Why Do Exercise Hemodynamics Matter? J Card Fail 2023; 29:1285-1287. [PMID: 37178756 DOI: 10.1016/j.cardfail.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Sergio Caravita
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine BG, Italy; Dyspnea and Pulmonary Hypertension Center, Department of Cardiology, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milano, Italy
| | - Claudia Baratto
- Dyspnea and Pulmonary Hypertension Center, Department of Cardiology, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milano, Italy
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, NC, USA; Department of Medicine, Duke University Medical Center, Durham, NC, USA.
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Baratto C, Faini A, Gallone GP, Dewachter C, Perego GB, Bondue A, Muraru D, Senni M, Badano LP, Parati G, Vachiéry JL, Caravita S. Pulmonary artery wedge pressure and left ventricular end-diastolic pressure during exercise in patients with dyspnoea. ERJ Open Res 2023; 9:00750-2022. [PMID: 37670852 PMCID: PMC10475984 DOI: 10.1183/23120541.00750-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/29/2023] [Indexed: 03/18/2023] Open
Abstract
Background Pulmonary artery wedge pressure (PAWP) during exercise, as a surrogate for left ventricular (LV) end-diastolic pressure (EDP), is used to diagnose heart failure with preserved ejection fraction (HFpEF). However, LVEDP is the gold standard to assess LV filling, end-diastolic PAWP (PAWPED) is supposed to coincide with LVEDP and mean PAWP throughout the cardiac cycle (PAWPM) better reflects the haemodynamic load imposed on the pulmonary circulation. The objective of the present study was to determine precision and accuracy of PAWP estimates for LVEDP during exercise, as well as the rate of agreement between these measures. Methods 46 individuals underwent simultaneous right and left heart catheterisation, at rest and during exercise, to confirm/exclude HFpEF. We evaluated: linear regression between LVEDP and PAWP, Bland-Altman graphs, and the rate of concordance of dichotomised LVEDP and PAWP ≥ or < diagnostic thresholds for HFpEF. Results At peak exercise, PAWPM and LVEDP, as well as PAWPED and LVEDP, were fairly correlated (R2>0.69, p<0.01), with minimal bias (+2 and 0 mmHg respectively) but large limits of agreement (±11 mmHg). 89% of individuals had concordant PAWP and LVEDP ≥ or <25 mmHg (Cohen's κ=0.64). Individuals with either LVEDP or PAWPM ≥25 mmHg showed a PAWPM increase relative to cardiac output (CO) changes (PAWPM/CO slope) >2 mmHg·L-1·min-1. Conclusions During exercise, PAWP is accurate but not precise for the estimation of LVEDP. Despite a good rate of concordance, these two measures might occasionally disagree.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
| | - Andrea Faini
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Gianluca P. Gallone
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium
| | - Giovanni B. Perego
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
| | - Antoine Bondue
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michele Senni
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Luigi P. Badano
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
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Lanzarone E, Baratto C, Vicenzi M, Villella F, Rota I, Dewachter C, Muraru D, Tomaselli M, Gavazzoni M, Badano LP, Senni M, Vachiéry JL, Parati G, Caravita S. Haemodynamic validation of the three-step HFA-PEFF algorithm to diagnose heart failure with preserved ejection fraction. ESC Heart Fail 2023. [PMID: 37321596 PMCID: PMC10375124 DOI: 10.1002/ehf2.14436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/09/2023] [Accepted: 05/23/2023] [Indexed: 06/17/2023] Open
Abstract
AIMS The HFA-PEFF algorithm (Heart Failure Association-Pre-test assessment, Echocardiography and natriuretic peptide score, Functional testing in cases of uncertainty, Final aetiology) is a three-step algorithm to diagnose heart failure with preserved ejection fraction (HFpEF). It provides a three-level likelihood of HFpEF: low (score < 2), intermediate (score 2-4), or high (score > 4). HFpEF may be confirmed in individuals with a score > 4 (rule-in approach). The second step of the algorithm is based on echocardiographic features and natriuretic peptide levels. The third step implements diastolic stress echocardiography (DSE) for controversial diagnostic cases. We sought to validate the three-step HFA-PEFF algorithm against a haemodynamic diagnosis of HFpEF based on rest and exercise right heart catheterization (RHC). METHODS AND RESULTS Seventy-three individuals with exertional dyspnoea underwent a full diagnostic work-up following the HFA-PEFF algorithm, including DSE and rest/exercise RHC. The association between the HFA-PEFF score and a haemodynamic diagnosis of HFpEF, as well as the diagnostic performance of the HFA-PEFF algorithm vs. RHC, was assessed. The diagnostic performance of left atrial (LA) strain < 24.5% and LA strain/E/E' < 3% was also assessed. The probability of HFpEF was low/intermediate/high in 8%/52%/40% of individuals at the second step of the HFA-PEFF algorithm and 8%/49%/43% at the third step. After RHC, 89% of patients were diagnosed as HFpEF and 11% as non-cardiac dyspnoea. The HFA-PEFF score resulted associated with the invasive haemodynamic diagnosis of HFpEF (P < 0.001). Sensitivity and specificity of the HFA-PEFF score for the invasive haemodynamic diagnosis of HFpEF were 45% and 100% for the second step of the algorithm and 46% and 88% for the third step of the algorithm. Neither age, sex, body mass index, obesity, chronic obstructive pulmonary disease, or paroxysmal atrial fibrillation influenced the performance of the HFA-PEFF algorithm, as these characteristics were similarly distributed over the true positive, true negative, false positive, and false negative cases. Sensitivity of the second step of the HFA-PEFF score was non-significantly improved to 60% (P = 0.08) by lowering the rule-in threshold to >3. LA strain alone had a sensitivity and specificity of 39% and 14% for haemodynamic HFpEF, increasing to 55% and 22% when corrected for E/E'. CONCLUSIONS As compared with rest/exercise RHC, the HFA-PEFF score lacks sensitivity: Half of the patients were wrongly classified as non-cardiac dyspnoea after non-invasive tests, with a minimal impact of DSE in modifying HFpEF likelihood.
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Affiliation(s)
- Ettore Lanzarone
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
| | - Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, Milan, 20149, Italy
| | - Marco Vicenzi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Villella
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, Milan, 20149, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Irene Rota
- UOC Cardiologia, Ospedale Civile di Legnano, ASST Ovest Milanese, Milan, Italy
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, Milan, 20149, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, Milan, 20149, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Mara Gavazzoni
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, Milan, 20149, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, Milan, 20149, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michele Senni
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, Milan, 20149, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Sergio Caravita
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, Milan, 20149, Italy
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Correction. ESC Heart Fail 2023; 10:2144. [PMID: 36941238 DOI: 10.1002/ehf2.14356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
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Mastoris I, Campain J, Lewis GD. Invasive exercise haemodynamics: an oracle in heart failure with preserved ejection fraction diagnosis and prognostication. Eur J Heart Fail 2023; 25:197-200. [PMID: 36644824 DOI: 10.1002/ejhf.2774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/08/2023] [Indexed: 01/17/2023] Open
Affiliation(s)
- Ioannis Mastoris
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph Campain
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Gregory D Lewis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Caravita S, Baratto C. Understanding mechanisms of Fontan failure: exercise haemodynamics to unmask diastolic dysfunction, again! Eur J Heart Fail 2023; 25:26-29. [PMID: 36519686 DOI: 10.1002/ejhf.2756] [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: 11/08/2022] [Revised: 12/04/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Milan, Italy.,Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
| | - Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Milan, Italy
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