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Vitarelli A, Miraldi F, Capotosto L, Galea N, Francone M, Marchitelli L, Viceconte N, Smaldone C, Mangieri E, Nguyen BL, Tanzilli G, Mancone M, Al-Kindy S. Comprehensive echocardiographic assessment of right ventricular function, pulmonary arterial elastic properties and ventricular-vascular coupling in adult patients with repaired tetralogy of fallot: clinical significance of 3D derived indices. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:1631-1641. [PMID: 37405609 DOI: 10.1007/s10554-023-02857-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/21/2023] [Indexed: 07/06/2023]
Abstract
We aimed to comprehensively analyze by three-dimensional speckle-tracking echocardiography (3DSTE) and Doppler echocardiography right ventricular (RV) performance, pulmonary arterial (PA) elastic properties and right ventricular-pulmonary artery coupling (RVPAC) in patients with repaired tetralogy of Fallot (rTOF) and assess the feasibility and clinical utility of related echocardiographic indices. Twenty-four adult patients with rTOF and twenty-four controls were studied. RV end-diastolic volume(3D-RVEDV), RV end-systolic volume(3D-RVESV), RV ejection fraction(3D-RVEF), RV longitudinal strain(3D-RVLS) and RV area strain(3D-RVAS) were calculated by 3DSTE. RV end-systolic area (RVESA) was obtained by planimetry. Pulmonary regurgitation (PR) was assessed as trivial/mild or significant by cardiac magnetic resonance (CMR) and color-Doppler. Pulmonary artery (PA) elastic properties were determined using two-dimensional/Doppler echocardiography. RV systolic pressure (RVSP) was measured using standard Doppler methods. RVPAC was assessed using various 3DSTE-derived parameters (3DRVAS/RVSP, 3DRVLS/RVESA, 3DRVAS/RVESV). Overall, 3DRVEF and 3DRVAS were impaired in rTOF patients compared with controls. PA pulsatility and capacitance were reduced (p = 0.003) and PA elastance was higher (p = 0.0007) compared to controls. PA elastance had a positive correlation with 3DRVEDV (r = 0.64, p = 0.002) and 3DRVAS (r = 0.51, p = 0.02). By ROC (receiver operating characteristics) analysis, 3DRVAS/RVESV, 3DRVAS/RVSP and 3DRVLS/RVESA cutoff values of 0.31%/mmHg, 0.57%/mmHg and 0.86%/mmHg, respectively, had 91%, 88% and 88% sensitivity and 81%, 81% and 79% specificity in identifying exercise capacity impairment. In rTOF patients increased 3DSTE-derived RV volumes and impaired RV ejection fraction and strain are associated with reduced PA pulsatility and capacitance and increased PA elastance. 3DSTE-derived RVPAC parameters using different afterload-markers are accurate indices of exercise capacity.
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Affiliation(s)
- Antonio Vitarelli
- Depts of Cardiology, Cardiac Surgery and Radiology, Sapienza University, Rome, Italy.
- Cardiodiagnostica, via Lima 35, Rome, 00198, Italy.
| | - Fabio Miraldi
- Depts of Cardiology, Cardiac Surgery and Radiology, Sapienza University, Rome, Italy
| | - Lidia Capotosto
- Depts of Cardiology, Cardiac Surgery and Radiology, Sapienza University, Rome, Italy
- Cardiodiagnostica, via Lima 35, Rome, 00198, Italy
| | - Nicola Galea
- Depts of Cardiology, Cardiac Surgery and Radiology, Sapienza University, Rome, Italy
| | - Marco Francone
- Depts of Cardiology, Cardiac Surgery and Radiology, Sapienza University, Rome, Italy
| | - Livia Marchitelli
- Depts of Cardiology, Cardiac Surgery and Radiology, Sapienza University, Rome, Italy
| | - Nicola Viceconte
- Depts of Cardiology, Cardiac Surgery and Radiology, Sapienza University, Rome, Italy
| | | | - Enrico Mangieri
- Depts of Cardiology, Cardiac Surgery and Radiology, Sapienza University, Rome, Italy
| | - Bich Lien Nguyen
- Depts of Cardiology, Cardiac Surgery and Radiology, Sapienza University, Rome, Italy
| | - Gaetano Tanzilli
- Depts of Cardiology, Cardiac Surgery and Radiology, Sapienza University, Rome, Italy
| | - Massimo Mancone
- Depts of Cardiology, Cardiac Surgery and Radiology, Sapienza University, Rome, Italy
| | - Sulaiman Al-Kindy
- Depts of Cardiology, Cardiac Surgery and Radiology, Sapienza University, Rome, Italy
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2
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AbdelMassih AF, Ismail HA, Nabil FM, Mabrouk AI, Abdel Aziz F. RSV-induced LV dysfunction, what can be the underlying cause? Pediatr Pulmonol 2023; 58:991-995. [PMID: 36562647 DOI: 10.1002/ppul.26290] [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] [Received: 10/15/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Antoine Fakhry AbdelMassih
- Department of Pediatrics, Pediatric Cardiology Unit, Kasr Al Ainy School of Medicine, Cairo University, Cairo, Egypt.,Cardiac Sciences' Department, Pediatric Cardiology Division, Sheikh Khalifa Medical City, Abu Dhabi, UAE
| | - Habiba-Allah Ismail
- Department of Pediatrics, Pediatrics' residency program, Kasr Al Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Fatima Mohamed Nabil
- Department of Pediatrics, Pediatrics' residency program, Kasr Al Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Aliaa Ibrahim Mabrouk
- Department of Pediatrics, Pediatrics' residency program, Kasr Al Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Faten Abdel Aziz
- Department of Pediatrics, Pediatric Cardiology Unit, Kasr Al Ainy School of Medicine, Cairo University, Cairo, Egypt
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3
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Kaestner M, Apitz C, Lammers AE. Cardiac catheterization in pediatric pulmonary hypertension: a systematic and practical approach. Cardiovasc Diagn Ther 2021; 11:1102-1110. [PMID: 34527536 DOI: 10.21037/cdt-20-395] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/29/2020] [Indexed: 11/06/2022]
Abstract
Significant progress in the understanding of the etiology, epidemiology, pathobiology and prognosis of pulmonary hypertension (PH) has been made over the last years. Especially in the pediatric patient population the etiology of PH is very heterogeneous. Nevertheless, the most recent change of the definition of PH to a mean pulmonary artery pressure (mPAP) >20 mmHg has been accepted by pediatricians for uniformity and concordance with adult physicians. Based on the diverse underlying medical conditions leading to PH, a comprehensive and systematic approach for diagnosis and treatment is mandatory. Cardiac catheterization remains the gold standard for invasive assessment and acute vasoreactivity testing (AVT) additionally providing detailed information about nature of PH. In most patients repeat cardiac catheterization may be helpful for evaluation of response to targeted PH treatment, risk stratification and indication for lung transplantation. However, the information and results taken from cardiac catheterization should be interpreted by experienced investigators only who are familiar with confounding factors that may influence the results. Here we provide an overview of current recommendations for invasive hemodynamic evaluation in pediatric PH. We point out different patient scenarios and provide a structured approach for AVT and response interpretation.
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Affiliation(s)
- Michael Kaestner
- University Children's Hospital Ulm, Division of Pediatric Cardiology, Ulm, Germany
| | - Christian Apitz
- University Children's Hospital Ulm, Division of Pediatric Cardiology, Ulm, Germany
| | - Astrid Elisabeth Lammers
- University Children's Hospital Münster, Division of Pediatric Cardiology, Albert-Schweitzer-Campus 1, Münster, Germany
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4
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Guigui S, Zaidi SI, Lee JJ, Elajami T, Mihos CG, Escolar E. Relationship between compliance and pulmonary vascular resistance in pulmonary arterial hypertension. J Thorac Dis 2020; 12:2971-2976. [PMID: 32642210 PMCID: PMC7330329 DOI: 10.21037/jtd.2020.02.20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 02/21/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pulmonary arterial compliance (PAC) was previously shown to be an important prognostic factor in pulmonary arterial hypertension (PAH), in addition to the conventional pulmonary vascular resistance (PVR). The product of PAC and PVR, the arterial time (RC) constant, expresses the logarithmic relationship between the hemodynamic parameters. The objective of the study was to test RC constant stability in PAH patients followed beyond 12 months after diagnosis, and to report possible RC variations in different etiologies. METHODS Fourteen PAH patients followed between 2008 and 2019 were included. Type 1 PAH was defined as a mean pulmonary artery pressure (PAP) ≥25 mmHg at rest and PVR ≥3 Wood units (WU). All patients who fulfilled WHO group I PAH criteria and had undergone two right heart catheterizations at least 1 year apart were included. The recorded hemodynamic data for each patient were used to compute PVR and PAC. RESULTS PAH etiologies included scleroderma (n=2), liver cirrhosis (n=1), hereditary hemorrhagic telangiectasia (HHT) (n=1), mixed connective tissue disease (MCTD) (n=3), and idiopathic (n=7). The RC constant remained stable for all 14 patients over a follow-up period of 3.9±2 years. Patients with MCTD displayed more favorable hemodynamics, evidenced by higher RC (12.54 vs. 10.01, P<0.01) and PAC values (2.59 vs. 1.62, P=0.02), when compared with non-MCTD PAH patients. For the entire cohort the mean PAP measured 51±14 mmHg at baseline, and 46±13 mmHg at follow-up, respectively. CONCLUSIONS The relationship between PAC and PVR remains stable in follow-up periods averaging 4 years, making compliance an important disease marker past the early stages. Patients with MCTD displayed more advantageous hemodynamic profiles when compared with patients with other PAH etiologies.
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Affiliation(s)
- Sarah Guigui
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Syed I. Zaidi
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - John J. Lee
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Tarec Elajami
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Christos G. Mihos
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
- Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Esteban Escolar
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
- Pulmonary Hypertension Clinic, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
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Bhattacharya S, Sen S, Levy PT, Rios DR. Comprehensive Evaluation of Right Heart Performance and Pulmonary Hemodynamics in Neonatal Pulmonary Hypertension : Evaluation of cardiopulmonary performance in neonatal pulmonary hypertension. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:10. [PMID: 30767138 DOI: 10.1007/s11936-019-0713-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Pulmonary hypertension is characterized by an elevation of pulmonary artery pressures and prolonged exposure of the right ventricle to high afterload that collectively contribute to morbidity and mortality in both the term and preterm infants. This review summarizes the pathogenesis, etiologies, and hemodynamic profiles of the conditions that result in pulmonary hypertension in neonates. We explore the application of echocardiographic techniques for the assessment of right ventricular performance and pulmonary hemodynamics that enhance and guide the diagnosis and management strategies in neonates. RECENT FINDINGS Clinical assessments based on the determinants of mean pulmonary artery pressures (pulmonary vascular resistance, pulmonary blood flow, and pulmonary capillary wedge pressure) provide a physiologic approach in determining the acute and chronic etiologies of pulmonary hypertension in neonates. In addition, advances in neonatal echocardiography now afford the capability to obtain quantitative information that often precedes the qualitative information acquired by conventional methods and also provide sensitive markers of right ventricle performance for prognostic information based on the determinants of mean pulmonary artery pressures. Neonatal pulmonary hypertension represents a physiologic spectrum that accounts for the variance in clinical presentation and response to therapies. Physiology-based approaches to etiological identification, coupled with the emerging echocardiographic methods for the assessment of pulmonary hypertension in neonates will likely help to identify cardiovascular compromise earlier, guide therapeutic intervention, monitor therapeutic effectiveness, and improve overall outcome.
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Affiliation(s)
- Soume Bhattacharya
- Division of Neonatology, Department of Paediatrics, Western University, London, ON, Canada
| | - Shawn Sen
- Divisions of Neonatology and Pediatric Cardiology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Philip T Levy
- Division of Newborn Medicine, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Hunnewell 436, Boston, MA, 02115, USA.
| | - Danielle R Rios
- Section of Neonatology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
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6
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Sehgal A, Gwini SM, Menahem S, Allison BJ, Miller SL, Polglase GR. Preterm growth restriction and bronchopulmonary dysplasia: the vascular hypothesis and related physiology. J Physiol 2018; 597:1209-1220. [PMID: 29746007 DOI: 10.1113/jp276040] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 04/27/2018] [Indexed: 12/12/2022] Open
Abstract
KEY POINTS Approximately 5-10% pregnancies are affected by fetal growth restriction. Preterm infants affected by fetal growth restriction have a higher incidence of bronchopulmonary dysplasia. The present study is the first to measure pulmonary artery thickness and stiffness. The findings show that impaired vasculogenesis may be a contributory factor in the higher incidence of bronchopulmonary dysplasia in preterm growth restricted infants. The study addresses the mechanistic link between fetal programming and vascular architecture and mechanics. ABSTRACT Bronchopulmonary dysplasia is the most common respiratory sequelae of prematurity and histopathologically features fewer, dysmorphic pulmonary arteries. The present study aimed to characterize pulmonary artery mechanics and cardiac function in preterm infants with fetal growth restriction (FGR) compared to those appropriate for gestational age (AGA) in the early neonatal period. This prospective study reviewed 40 preterm infants between 28 to 32 weeks gestational age (GA). Twenty infants had a birthweight <10th centile and were compared with 20 preterm AGA infants. A single high resolution echocardiogram was performed to measure right pulmonary arterial and right ventricular (RV) indices. The GA and birthweight of FGR and AGA infants were 29.8 ± 1.3 vs. 30 ± 0.9 weeks (P = 0.78) and 923.4 g ± 168 vs. 1403 g ± 237 (P < 0.001), respectively. Assessments were made at 10.5 ± 1.3 days after birth. The FGR infants had significantly thicker right pulmonary artery inferior wall (843.5 ± 68 vs. 761 ± 40 μm, P < 0.001) with reduced pulsatility (51.6 ± 7.6 μm vs. 59.7 ± 7.5 μm, P = 0.001). The RV contractility [fractional area change (28.7 ± 3.8% vs 32.5 ± 3.1%, P = 0.001), tricuspid annular peak systolic excursion (TAPSE) (5.2 ± 0.3% vs. 5.9 ± 0.7%, P = 0.0002) and myocardial performance index (0.35 ± 0.03 vs. 0.28 ± 0.02, P < 0.001)] was significantly impaired in FGR infants. Significant correlation between RV longitudinal contractility (TAPSE) and time to peak velocity/RV ejection time (measure of RV afterload) was noted (r2 = 0.5, P < 0.001). Altered pulmonary vascular mechanics and cardiac performance reflect maladaptive changes in response to utero-placental insufficiency. Whether managing pulmonary vascular disease will alter clinical outcomes remains to be studied prospectively.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia.,Department of Pediatrics, Monash University, Melbourne, VIC, Australia
| | - Stella M Gwini
- School of Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia
| | - Samuel Menahem
- Emeritus Head, Paediatric and Foetal Cardiac Units, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia
| | - Beth J Allison
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
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7
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Gerringer JW, Wagner JC, Vélez-Rendón D, Valdez-Jasso D. Lumped-parameter models of the pulmonary vasculature during the progression of pulmonary arterial hypertension. Physiol Rep 2018; 6. [PMID: 29411543 PMCID: PMC5901176 DOI: 10.14814/phy2.13586] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 12/16/2017] [Accepted: 12/19/2017] [Indexed: 01/04/2023] Open
Abstract
A longitudinal study of monocrotaline-induced pulmonary arterial hypertension (PAH) was carried out in Sprague-Dawley rats to investigate the changes in impedance (comprising resistance and compliance) produced by elevated blood pressure. Using invasively measured blood flow as an input, blood pressure was predicted using 3- and 4-element Windkessel (3WK, 4WK) type lumped-parameter models. Resistance, compliance, and inductance model parameters were obtained for the five different treatment groups via least-squares errors. The treated animals reached levels of hypertension, where blood pressure increased two folds from control to chronic stage of PAH (mean pressure went from 24 ± 5 to 44 ± 6 mmHg, P < 0.0001) but blood flow remained overall unaffected. Like blood pressure, the wave-reflection coefficient significantly increased at the advanced stage of PAH (0.26 ± 0.09 to 0.52 ± 0.09, P < 0.0002). Our modeling efforts revealed that resistances and compliance changed during the disease progression, where changes in compliance occur before the changes in resistance. However, resistance and compliance are not directly inversely related. As PAH develops, resistances increase nonlinearly (Rd exponentially and R at a slower rate) while compliance linearly decreases. And while 3WK and 4WK models capture the pressure-flow relation in the pulmonary vasculature during PAH, results from Akaike Information Criterion and sensitivity analysis allow us to conclude that the 3WK is the most robust and accurate model for this system. Ninety-five percent confidence intervals of the predicted model parameters are included for the population studied. This work establishes insight into the complex remodeling process occurring in PAH.
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Affiliation(s)
- Jesse W Gerringer
- Department of Bioengineering, University of Illinois at Chicago, Chicago, Illinois.,Department of Biomedical Engineering, Marquette University, Milwaukee, Wisconsin
| | - Julie C Wagner
- Department of Bioengineering, University of Illinois at Chicago, Chicago, Illinois.,Department of Biomedical Engineering, Marquette University, Milwaukee, Wisconsin
| | - Daniela Vélez-Rendón
- Department of Bioengineering, University of Illinois at Chicago, Chicago, Illinois
| | - Daniela Valdez-Jasso
- Department of Bioengineering, University of Illinois at Chicago, Chicago, Illinois.,Department of Bioengineering, University of California at San Diego, La Jolla, California
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de Boode WP, Singh Y, Molnar Z, Schubert U, Savoia M, Sehgal A, Levy PT, McNamara PJ, El-Khuffash A, on behalf of the European Special Interest Group ‘Neonatologist Performed Echocardiography’ (NPE) AustinT.12BohlinK.13BravoM. C.14BreatnachC. R.15BreindahlM.16DempseyE.17GrovesA. M.18GuptaS.19Horsberg EriksenB.20NestaasE.212223RogersonS. R.24RoehrC. C.25SchwarzC. E.26SliekerM. G.27TissotC.28van der LeeR.29van LaereD.30van OvermeireB.31van WykL.32. Application of Neonatologist Performed Echocardiography in the assessment and management of persistent pulmonary hypertension of the newborn. Pediatr Res 2018; 84:68-77. [PMID: 30072805 PMCID: PMC6257221 DOI: 10.1038/s41390-018-0082-0] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pulmonary hypertension contributes to morbidity and mortality in both the term newborn infant, referred to as persistent pulmonary hypertension of the newborn (PPHN), and the premature infant, in the setting of abnormal pulmonary vasculature development and arrested growth. In the term infant, PPHN is characterized by the failure of the physiological postnatal decrease in pulmonary vascular resistance that results in impaired oxygenation, right ventricular failure, and pulmonary-to-systemic shunting. The pulmonary vasculature is either maladapted, maldeveloped, or underdeveloped. In the premature infant, the mechanisms are similar in that the early onset pulmonary hypertension (PH) is due to pulmonary vascular immaturity and its underdevelopment, while late onset PH is due to the maladaptation of the pulmonary circulation that is seen with severe bronchopulmonary dysplasia. This may lead to cor-pulmonale if left undiagnosed and untreated. Neonatologist performed echocardiography (NPE) should be considered in any preterm or term neonate that presents with risk factors suggesting PPHN. In this review, we discuss the risk factors for PPHN in term and preterm infants, the etiologies, and the pathophysiological mechanisms as they relate to growth and development of the pulmonary vasculature. We explore the applications of NPE techniques that aid in the correct diagnostic and pathophysiological assessment of the most common neonatal etiologies of PPHN and provide guidelines for using these techniques to optimize the management of the neonate with PPHN.
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Affiliation(s)
- Willem P. de Boode
- grid.461578.9Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children’s Hospital, Nijmegen, The Netherlands
| | - Yogen Singh
- 0000 0004 0383 8386grid.24029.3dAddenbrooke′s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Zoltan Molnar
- 0000 0001 2306 7492grid.8348.7John Radcliffe Hospital, Oxford, United Kingdom
| | - Ulf Schubert
- 0000 0004 1937 0626grid.4714.6Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Marilena Savoia
- grid.411492.bAzienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine, Italy
| | - Arvind Sehgal
- 0000 0004 1936 7857grid.1002.3Department of Pediatrics, Monash University, Melbourne, Australia
| | - Philip T. Levy
- 0000 0001 2355 7002grid.4367.6Department of Pediatrics, Washington University School of Medicine, Saint Louis, MO USA ,grid.429583.1Department of Pediatrics, Goryeb Children’s Hospital, Morristown, NJ USA
| | - Patrick J. McNamara
- 0000 0001 2157 2938grid.17063.33Departments of Pediatrics and Physiology, University of Toronto, Toronto, ON Canada
| | - Afif El-Khuffash
- 0000 0004 0617 7587grid.416068.dDepartment of Neonatology, The Rotunda Hospital, Dublin, Ireland ,0000 0004 0488 7120grid.4912.eDepartment of Pediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
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9
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Medrek SK, Kloefkorn C, Nguyen DTM, Graviss EA, Frost AE, Safdar Z. Longitudinal change in pulmonary arterial capacitance as an indicator of prognosis and response to therapy and in pulmonary arterial hypertension. Pulm Circ 2017; 7:399-408. [PMID: 28597758 PMCID: PMC5467926 DOI: 10.1177/2045893217698715] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a chronic progressive disease that leads to right heart failure and death. Pulmonary arterial capacitance (PAC), defined as stroke volume divided by the pulmonary pulse pressure, has been identified as a prognostic factor in PAH. The impact of changes in PAC over time, however, is unclear. We evaluated changes in PAC over time to determine if such changes predicted transplant-free survival. A single-center retrospective study of consecutive group 1 PAH patients who had two or more right heart catheterizations (RHC) between January 2007 and June 2016 was undertaken. Hemodynamic data, clinical data, and outcomes were collected. Univariate and multivariate Cox proportional-hazards modelling to identify the contribution of risk factors for a composite outcome of death or lung transplantation was done. Mixed-effects logistic regression was performed to investigate the association between the change in PAC value over time and the composite outcome. A P value < 0.05 was considered significant. In total, 109 consecutive patients with a total of 300 RHC data were identified. PAC correlated inversely with functional status ( P < 0.001) and inversely with pulmonary vascular resistance ( P < 0.001). PAC values increased with the addition of new PAH-specific medications. Mixed effects logistic regression modeling using longitudinal data showed that a decrease in PAC over the study period was associated with increased mortality and transplantation (adjusted P = 0.039) over the study period. Change in PAC was a better predictor of outcome over the study period than baseline PAC or changes in other hemodynamic or clinical parameters. Decreases in PAC were predictive of increased mortality or transplantation in patients with group 1 PAH. There was a trend towards increased PAC in response to the addition of a PAH-specific medication. Our data support the use of PAC as a therapeutic target in PAH.
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Affiliation(s)
- Sarah K Medrek
- 1 Department of Pulmonary, Sleep, and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Chad Kloefkorn
- 1 Department of Pulmonary, Sleep, and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Duc T M Nguyen
- 2 Institute for Academic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Edward A Graviss
- 2 Institute for Academic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Adaani E Frost
- 2 Institute for Academic Medicine, Houston Methodist Hospital, Houston, TX, USA.,3 Weill Cornell College of Medicine, New York, NY, USA
| | - Zeenat Safdar
- 2 Institute for Academic Medicine, Houston Methodist Hospital, Houston, TX, USA.,3 Weill Cornell College of Medicine, New York, NY, USA
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10
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Hayabuchi Y, Ono A, Homma Y, Kagami S. Noninvasive assessment of pulmonary arterial capacitance by pulmonary annular motion velocity in children with ventricular septal defect. Cardiovasc Ultrasound 2016; 14:38. [PMID: 27604100 PMCID: PMC5015327 DOI: 10.1186/s12947-016-0081-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 08/31/2016] [Indexed: 11/17/2022] Open
Abstract
Background We hypothesized that longitudinal pulmonary arterial deformation during the cardiac cycle reflects pulmonary arterial capacitance. To examine this hypothesis, we assessed whether tissue Doppler-derived pulmonary annular motion could serve as a novel way to evaluate pulmonary arterial capacitance in pediatric patients with ventricular septal defect (VSD). Methods In this prospective study, pulmonary annular velocity was measured in children (age, 6 months–5 years) with a preoperative VSD (VSD group, n = 35) and age-matched healthy children (Control group, n = 23). Pulmonary artery capacitance was calculated by two methods. Systolic pulmonary arterial capacitance (sPAC) was expressed as the stroke volume/pulmonary arterial pulse pressure. Diastolic pulmonary arterial capacitance (dPAC) was determined according to a two-element windkessel model of the pulmonary arterial diastolic pressure profile. Results Pulmonary annular velocity waveforms comprised systolic bimodal (s1′ and s2′) and diastolic e’ and a’ waves in all participants. The peak velocities of s1′, s2′, and e’ were significantly lower in the VSD group than in the Control group. On multiple regression analysis, sPAC was an independent variable affecting the peak velocities of the s1′, s2′, and e’ waves (β = 0.41, 0.62, and 0.35, respectively). The dPAC affected the s1′ wave peak velocity (β = 0.34). The time durations of the s1′ and e’ waves were independently determined by the sPAC (β = 0.49 and 0.27). Conclusion Pulmonary annular motion velocity evaluated using tissue Doppler is a promising method of assessing pulmonary arterial capacitance in children with VSD. Electronic supplementary material The online version of this article (doi:10.1186/s12947-016-0081-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yasunobu Hayabuchi
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima, 770-8305, Japan.
| | - Akemi Ono
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima, 770-8305, Japan
| | - Yukako Homma
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima, 770-8305, Japan
| | - Shoji Kagami
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima, 770-8305, Japan
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11
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Mechanical characteristics of the pulmonary artery in beagle dogs with hepatopulmonary syndrome and portopulmonary hypertension. Biomed Rep 2015; 4:51-54. [PMID: 26870333 DOI: 10.3892/br.2015.526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 09/10/2015] [Indexed: 02/07/2023] Open
Abstract
The continuous changes in pulmonary hemodynamic properties in hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PoPH) have not been fully characterized in large animal models of HPS and PoPH. Beagle dog models of HPS and PoPH were induced by chronic common bile duct ligation and Sephadex microspheres, respectively. The model was validated by catheter examination and pathological analyses, and the hemodynamic characteristics of the models were observed. The results revealed that the cross-sectional area of the blood vessel was significantly increased in HPS models, but it was significantly decreased in the PoPH models. Furthermore, the resistance of pulmonary circulation was elevated in models of HPS, but it was decreased in models of PoPH. The present findings renew the traditional view that pulmonary hypertension is due to the enhanced peripheral resistance.
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Nagiub M, Lee S, Guglani L. Echocardiographic Assessment of Pulmonary Hypertension in Infants with Bronchopulmonary Dysplasia: Systematic Review of Literature and a Proposed Algorithm for Assessment. Echocardiography 2014; 32:819-33. [DOI: 10.1111/echo.12738] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Mohamed Nagiub
- Division of Pediatric Cardiology; Department of Pediatrics; Children Hospital of Richmond; Virginia Commonwealth University; Richmond Virginia
| | - Sam Lee
- Division of Pediatric Cardiology; Department of Pediatrics; Children Hospital of Richmond; Virginia Commonwealth University; Richmond Virginia
| | - Lokesh Guglani
- Division of Pediatric Pulmonary Medicine; The Carman and Ann Adams Department of Pediatrics; Children's Hospital of Michigan; Wayne State University School of Medicine; Detroit Michigan
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13
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Moceri P, Baudouy D, Chiche O, Cerboni P, Bouvier P, Chaussade C, Ferrari E. Imaging in pulmonary hypertension: Focus on the role of echocardiography. Arch Cardiovasc Dis 2014; 107:261-71. [PMID: 24746538 DOI: 10.1016/j.acvd.2014.02.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 02/11/2014] [Accepted: 02/13/2014] [Indexed: 10/25/2022]
Abstract
Patients with pulmonary hypertension must be evaluated using a multimodality approach to ensure a correct diagnosis and basal evaluation as well as a prognostic assessment. Beyond the assessment of pulmonary pressures, the echocardiographical examination allows the evaluation of right ventricular adaptation to elevated afterload. Numbers of variables are commonly used in the assessment of the pulmonary hypertension patient in order to detect changes in right heart geometry, right-to-left interaction and right ventricular dysfunction. Whereas an isolated change in one echocardiographical variable is not meaningful, multiple echocardiographical variable modifications together provide accurate information. In this review, we will link pulmonary hypertension pathophysiological changes with echocardiographical indices and describe the clinical implications of echocardiographical findings.
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Affiliation(s)
- Pamela Moceri
- Service de cardiologie, hôpital Pasteur, CHU de Nice, 30, avenue de la Voie-Romaine, BP69, CS 51069, 06001 Nice cedex 1, France.
| | - Delphine Baudouy
- Service de cardiologie, hôpital Pasteur, CHU de Nice, 30, avenue de la Voie-Romaine, BP69, CS 51069, 06001 Nice cedex 1, France
| | - Olivier Chiche
- Service de cardiologie, hôpital Pasteur, CHU de Nice, 30, avenue de la Voie-Romaine, BP69, CS 51069, 06001 Nice cedex 1, France
| | - Pierre Cerboni
- Service de cardiologie, hôpital Pasteur, CHU de Nice, 30, avenue de la Voie-Romaine, BP69, CS 51069, 06001 Nice cedex 1, France
| | - Priscille Bouvier
- Service de cardiologie, hôpital Pasteur, CHU de Nice, 30, avenue de la Voie-Romaine, BP69, CS 51069, 06001 Nice cedex 1, France
| | - Claire Chaussade
- Service de cardiologie, hôpital Pasteur, CHU de Nice, 30, avenue de la Voie-Romaine, BP69, CS 51069, 06001 Nice cedex 1, France
| | - Emile Ferrari
- Service de cardiologie, hôpital Pasteur, CHU de Nice, 30, avenue de la Voie-Romaine, BP69, CS 51069, 06001 Nice cedex 1, France
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14
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Nemes A, Forster T. [Evaluation of pulmonary artery stiffness using routine clinical imaging methods]. Orv Hetil 2013; 154:1931-3. [PMID: 24292110 DOI: 10.1556/oh.2013.29767] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Recently, there has been much debate about pulmonary hypertension due to modern therapeutic options available. Arterial hypertension is frequently associated with stiffening of a given artery. The aim of the present review is to present clinical imaging methods for the evaluation of the function and stiffness of the pulmonary artery.
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Affiliation(s)
- Attila Nemes
- Szegedi Tudományegyetem, Szent-Györgyi Albert Klinikai Központ, Általános Orvostudományi Kar II. Belgyógyászati Klinika és Kardiológiai Központ Szeged Korányi fasor 6. 6720
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15
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Takatsuki S, Ivy DD. Current challenges in pediatric pulmonary hypertension. Semin Respir Crit Care Med 2013; 34:627-44. [PMID: 24037630 DOI: 10.1055/s-0033-1356461] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Pulmonary arterial hypertension (PAH) in the pediatric population is associated with a variety of underlying diseases and causes, significantly morbidity and mortality. In the majority of patients, PAH in children is idiopathic or associated with congenital heart disease (CHD), with pulmonary hypertension (PH) associated with connective tissue disease, a rare cause in children. Classification of pediatric PH has generally followed the WHO classification, but recognition of the importance of fetal origins of PH and developmental abnormalities have led to the formation of a new pediatric-specific classification. Incidence data from the Netherlands has revealed an annual incidence and point prevalence of 0.7 and 4.4 for idiopathic PAH and 2.2 and 15.6 for associated pulmonary arterial hypertension-CHD cases per million children. Although the treatment with new selective pulmonary vasodilators offers hemodynamic and functional improvement in pediatric populations, the treatments in children largely depend on results from evidence-based adult studies and experience of clinicians treating children. A recent randomized clinical trial of sildenafil and its long-term extension has led to disparate recommendations in the United States and Europe.
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Affiliation(s)
- Shinichi Takatsuki
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
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16
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Abstract
During the progression of pulmonary hypertension (PH), proximal pulmonary arteries (PAs) undergo remodeling such that they become thicker and the elastic modulus increases. Both of these changes increase the vascular stiffness. The increase in pulmonary vascular stiffness contributes to increased right ventricular (RV) afterload, which causes RV hypertrophy and eventually failure. Studies have found that proximal PA stiffness or its inverse, compliance, is strongly related to morbidity and mortality in patients with PH. Therefore, accurate in vivo measurement of PA stiffness is useful for prognoses in patients with PH. It is also important to understand the structural changes in PAs that occur with PH that are responsible for stiffening. Here, we briefly review the most common parameters used to quantify stiffness and in vivo and in vitro methods for measuring PA stiffness in human and animal models. For in vivo approaches, we review invasive and noninvasive approaches that are based on measurements of pressure and inner or outer diameter or cross-sectional area. For in vitro techniques, we review several different testing methods that mimic one, two or several aspects of physiological loading (e.g., uniaxial and biaxial testing, dynamic inflation-force testing). Many in vivo and in vitro measurement methods exist in the literature, and it is important to carefully choose an appropriate method to measure PA stiffness accurately. Therefore, advantages and disadvantages of each approach are discussed.
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Affiliation(s)
- Lian Tian
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Naomi C. Chesler
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Tian L, Lammers SR, Kao PH, Albietz JA, Stenmark KR, Qi HJ, Shandas R, Hunter KS. Impact of residual stretch and remodeling on collagen engagement in healthy and pulmonary hypertensive calf pulmonary arteries at physiological pressures. Ann Biomed Eng 2012; 40:1419-33. [PMID: 22237861 DOI: 10.1007/s10439-012-0509-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 01/04/2012] [Indexed: 11/29/2022]
Abstract
Understanding the mechanical behavior of proximal pulmonary arteries (PAs) is crucial to evaluating pulmonary vascular function and right ventricular afterload. Early and current efforts focus on these arteries' histological changes, in vivo pressure-diameter behavior and mechanical properties under in vitro mechanical testing. However, the in vivo stretch and stress states remain poorly characterized. To further understand the mechanical behavior of the proximal PAs under physiological conditions, this study computed the residual stretch and the in vivo circumferential stretch state in the main pulmonary arteries in both control and hypertensive calves by using in vitro and in vivo artery geometry data, and modeled the impact of residual stretch and arterial remodeling on the in vivo circumferential stretch distribution and collagen engagement in the main pulmonary artery. We found that the in vivo circumferential stretch distribution in both groups was nonuniform across the vessel wall with the largest stretch at the outer wall, suggesting that collagen at the outer wall would engage first. It was also found that the circumferential stretch was more uniform in the hypertensive group, partially due to arterial remodeling that occurred during their hypoxic treatment, and that their onset of collagen engagement occurred at a higher pressure. It is concluded that the residual stretch and arterial remodeling have strong impact on the in vivo stretch state and the collagen engagement and thus the mechanical behavior of the main pulmonary artery in calves.
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Affiliation(s)
- Lian Tian
- Department of Mechanical Engineering, University of Colorado, Boulder, CO, USA.
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Kimura S, Nakahata Y, Honda T, Ando H, Ogata S, Akiyama K, Ogihara Y, Ishii M. Noninvasive assessment of pulmonary vascular resistance and pressure in patients with congenital heart disease: a new method using M-mode echocardiography. J Echocardiogr 2011; 9:137-41. [PMID: 27277290 DOI: 10.1007/s12574-011-0095-8] [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: 07/24/2010] [Revised: 05/19/2011] [Accepted: 05/20/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND The accurate evaluation of pulmonary vascular resistance (PVR) and mean pulmonary artery pressure is important to determine the optimal management and therapeutic strategy for patients with congenital heart disease (CHD). We evaluated the PVR and mean pulmonary artery pressure in 46 patients with several CHD types using the interventricular septum (IVS) motion determined by M-mode echocardiography. METHODS We divided the patients into 2 groups according to the different IVS motions. We measured the maximum anterior displacement from the baseline during early systole (a) and the maximum posterior displacement from the baseline during early diastole (b). We defined type A to be a/b greater than or equal to 1.0, and type B to be a/b less than 1.0. RESULTS The PVR and mean pulmonary artery pressure in type A patients were significantly higher than those in type B patients (p < 0.05). Type A IVS motion predicted patients with high PVR (>2.5 unit/m(2)) and high mean pulmonary artery pressure (>25 mmHg) (sensitivity 89%, specificity 89% and sensitivity 70%, specificity 91%, respectively). CONCLUSIONS Our method can noninvasively separate high and low PVR among patients with CHD. This noninvasive method is therefore considered to be useful in the management of patients with CHD in a clinical setting.
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Affiliation(s)
- Sumito Kimura
- Department of Pediatrics, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yayoi Nakahata
- Department of Pediatrics, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Takashi Honda
- Department of Pediatrics, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Hisashi Ando
- Department of Pediatrics, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Shohei Ogata
- Department of Pediatrics, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Kazumasa Akiyama
- Department of Pediatrics, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yoshito Ogihara
- Department of Pediatrics, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Masahiro Ishii
- Department of Pediatrics, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan.
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Abstract
PURPOSE OF REVIEW Transposition of the great arteries (TGA) is a complex congenital heart defect usually defined within the group of conotruncal defects. Some astonishing similarities between the spiral pattern of great arteries and the spiral pattern of snail shells and a possible common genetic mechanism of normal and abnormal anatomical aspects of the heart and shells are examined. RECENT FINDINGS The pulmonary vascular resistances in TGA and ventricular septal defect (VSD) need to be assessed before surgery, as they are the key factors for the success of the surgical procedure. A noninvasive method has been proposed to assess this key factor. A first series of the pregnancy outcomes in young women after arterial switch operation (ASO) is promising and encouraging for even better results. The systemic failing right ventricle (RV) is treated empirically using the same drugs and devices as for the failing left ventricle. The rationale for the treatment of ventricular failure, similar or different for predominantly right or left ventricle, is debated. The results of Rastelli operation are compared with those of the other surgical procedures for the treatment of TGA, VSD and pulmonary stenosis, namely reparation a l'ètage ventriculaire and Nikaidoh interventions. SUMMARY This review outlines some new aspects of the embryologic cardiac development and reveals astonishing similarities between heart and shells. A new diagnostic noninvasive method for measuring pulmonary vascular resistances, the pregnancy outcome of a first series of women operated by ASO, and the pharmacological and cardiac devices used in the failing systemic RV are presented. Finally, the review comments on the Rastelli operation as the 'gold standard' for TGA, VSD, and pulmonary stenosis.
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Hunter KS, Lammers SR, Shandas R. Pulmonary vascular stiffness: measurement, modeling, and implications in normal and hypertensive pulmonary circulations. Compr Physiol 2011; 1:1413-35. [PMID: 23733649 PMCID: PMC4113421 DOI: 10.1002/cphy.c100005] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
This article introduces the concept of pulmonary vascular stiffness, discusses its increasingly recognized importance as a diagnostic marker in the evaluation of pulmonary vascular disease, and describes methods to measure and model it clinically, experimentally, and computationally. It begins with a description of systems-level methods to evaluate pulmonary vascular compliance and recent clinical efforts in applying such techniques to better predict patient outcomes in pulmonary arterial hypertension. It then progresses from the systems-level to the local level, discusses proposed methods by which upstream pulmonary vessels increase in stiffness, introduces concepts around vascular mechanics, and concludes by describing recent work incorporating advanced numerical methods to more thoroughly evaluate changes in local mechanical properties of pulmonary arteries.
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Affiliation(s)
- Kendall S. Hunter
- Department of Bioengineering, University of Colorado at Denver Anschutz Medical Campus (UCD-AMC), Aurora, Colorado
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Denver, UCD-AMC, Aurora, Colorado
| | - Steven R. Lammers
- Department of Bioengineering, University of Colorado at Denver Anschutz Medical Campus (UCD-AMC), Aurora, Colorado
- Cardiovascular Pulmonary (CVP) Research Laboratory, UCD-AMC, Aurora, Colorado
| | - Robin Shandas
- Department of Bioengineering, University of Colorado at Denver Anschutz Medical Campus (UCD-AMC), Aurora, Colorado
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Denver, UCD-AMC, Aurora, Colorado
- Department of Surgery, UCD-AMC, Aurora, Colorado
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Oishi P, Datar SA, Fineman JR. Pediatric pulmonary arterial hypertension: current and emerging therapeutic options. Expert Opin Pharmacother 2011; 12:1845-64. [PMID: 21609302 DOI: 10.1517/14656566.2011.585636] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is a rare disease in neonates, infants and children that is associated with significant morbidity and mortality. An adequate understanding of the controlling pathophysiologic mechanisms is lacking and although mortality has decreased as therapeutic options have increased over the past several decades, outcomes remain unacceptable. AREAS COVERED This review summarizes the currently available therapies for neonates, infants and children with PAH and describes emerging therapies in the context of what is known about the underlying pathophysiology of the disease. EXPERT OPINION All of the currently approved PAH therapies impact one of three endothelial-based pathways: nitric oxide-guanosine-3'-5'cyclic monophosphate, prostacyclin or endothelin-1. The beneficial effects of these agents may relate to their impact on pulmonary vascular tone, and/or their antiproliferative and antithrombotic properties. Fundamental advances in PAH therapy are likely to relate to: i) a better understanding of PAH subpopulations, allowing for therapies to be better tailored to individual patients and pathophysiologic processes; and ii) therapies that promote the regression of advanced structural remodeling.
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Affiliation(s)
- Peter Oishi
- Cardiovascular Research Institute, Division of Critical Care Medicine, University of California-San Francisco, 513 Parnassus Avenue, San Francisco, CA 94143-1346, USA.
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22
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Subramanyan R. Operability in transposition of great arteries with ventricular septal defect: A difficult question - is the answer really so simple? Ann Pediatr Cardiol 2011; 4:45-6. [PMID: 21677805 PMCID: PMC3104533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Raghavan Subramanyan
- Frontier Lifeline Hospital and Dr. KM Cherian Heart Foundation, India,Address for correspondence: Prof. Raghavan Subramanyan, Frontier Lifeline Hospital and Dr. KM Cherian Heart Foundation R-30-C, Ambattur Industrial Estate Road, Chennai, India. E-mail:
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23
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Ivy D, Saji BT. A New Era in Medical Management of Severe Pediatric Pulmonary Arterial Hypertension. NIHON SHONI JUNKANKI GAKKAI ZASSHI = PEDIATRIC CARDIOLOGY AND CARDIAC SURGERY 2010; 26:206-218. [PMID: 23264720 PMCID: PMC3527842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a life-threatening disease whose prognosis has changed dramatically over the past decade since the introduction of new therapeutic agents as well as the off-label application of adult pulmonary hypertension specific therapies to children. Nevertheless, PAH still has no cure and the aim of treatment is to prolong survival by improving quality of life, symptoms, exercise capacity and hemodynamics. The selection of appropriate therapies for PH is complex and must be carefully chosen according to the etiology and pulmonary vasoreactivity. As insight advances into mechanisms responsible for the development of PAH, the introduction of novel therapeutic agents will hopefully further improve the outcome of this incurable disease.
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Affiliation(s)
- Dunbar Ivy
- Department of Pediatrics, University of Colorado Denver School of Medicine, Denver, Colorado, USA
| | - Ben T Saji
- Department of Pediatrics, Toho University, Medical Center, Tokyo, Japan
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Hunter KS, Albietz JA, Lee PF, Lanning CJ, Lammers SR, Hofmeister SH, Kao PH, Qi HJ, Stenmark KR, Shandas R. In vivo measurement of proximal pulmonary artery elastic modulus in the neonatal calf model of pulmonary hypertension: development and ex vivo validation. J Appl Physiol (1985) 2010; 108:968-75. [PMID: 20093662 DOI: 10.1152/japplphysiol.01173.2009] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Developing clinical work suggests that vascular stiffening plays a role in the progression of pulmonary hypertension (PH), while recent studies in animal models of hypoxic PH have found significant proximal vascular stiffening in the diseased population. Here, we develop and validate a minimally invasive, clinically realizable method to estimate the local elastic modulus of the proximal pulmonary arteries from pressure-diameter (PD) data. PD measurements were made in the main pulmonary arteries of 16 calves; lumen diameter was assessed using color M-mode tissue Doppler imaging ultrasound, while pressure was measured via catheter. Two methods corresponding to thin-walled pressure vessel theory ("thin") and Lame's equation for a thick-walled cylinder ("thick") were used to approximate the artery elastic modulus from PD measurements. The harvested arteries were tested independently to determine their "true" ex vivo elastic modulus and stiffness. Both approximations displayed excellent correlation with ex vivo elastic modulus of the calf main pulmonary artery (thin r(2) = 0.811; thick r(2) = 0.844; both P < 0.01). Bland-Altman analysis indicated that the thick-walled approximation has better overall agreement with ex vivo modulus. The approximations displayed quantitatively distinct regression slopes that were statistically different (P = 0.02). The elastic modulus of the main pulmonary artery can be reasonably estimated from combined color M-mode tissue Doppler imaging ultrasound and catheter pressure measurements in calves. Such measurements may be a valuable tool in the diagnosis and treatment of human PH.
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Affiliation(s)
- Kendall S Hunter
- Center for Bioengineering, University of Colorado at Denver, Anschutz Medical Campus, Aurora, Colorado 80045, USA.
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Stenmark KR, Meyrick B, Galie N, Mooi WJ, McMurtry IF. Animal models of pulmonary arterial hypertension: the hope for etiological discovery and pharmacological cure. Am J Physiol Lung Cell Mol Physiol 2009; 297:L1013-32. [DOI: 10.1152/ajplung.00217.2009] [Citation(s) in RCA: 589] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
At present, six groups of chronic pulmonary hypertension (PH) are described. Among these, group 1 (and 1′) comprises a group of diverse diseases termed pulmonary arterial hypertension (PAH) that have several pathophysiological, histological, and prognostic features in common. PAH is a particularly severe and progressive form of PH that frequently leads to right heart failure and premature death. The diagnosis of PAH must include a series of defined clinical parameters, which extend beyond mere elevations in pulmonary arterial pressures and include precapillary PH, pulmonary hypertensive arteriopathy (usually with plexiform lesions), slow clinical onset (months or years), and a chronic time course (years) characterized by progressive deterioration. What appears to distinguish PAH from other forms of PH is the severity of the arteriopathy observed, the defining characteristic of which is “plexogenic arteriopathy.” The pathogenesis of this arteriopathy remains unclear despite intense investigation in a variety of animal model systems. The most commonly used animal models (“classic” models) are rodents exposed to either hypoxia or monocrotaline. Newer models, which involve modification of classic approaches, have been developed that exhibit more severe PH and vascular lesions, which include neointimal proliferation and occlusion of small vessels. In addition, genetically manipulated mice have been generated that have provided insight into the role of specific molecules in the pulmonary hypertensive process. Unfortunately, at present, there is no perfect preclinical model that completely recapitulates human PAH. All models, however, have provided and will continue to provide invaluable insight into the numerous pathways that contribute to the development and maintenance of PH. Use of both classic and newly developed animal models will allow continued rigorous testing of new hypotheses regarding pathogenesis and treatment. This review highlights progress that has been made in animal modeling of this important human condition.
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Stepping Away From Ritual Right Heart Catheterization Into the Era of Noninvasively Measured Pulmonary Artery Pressure. J Am Soc Echocardiogr 2009; 22:820-2. [DOI: 10.1016/j.echo.2009.05.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Shifren A, Durmowicz AG, Knutsen RH, Faury G, Mecham RP. Elastin insufficiency predisposes to elevated pulmonary circulatory pressures through changes in elastic artery structure. J Appl Physiol (1985) 2008; 105:1610-9. [PMID: 18772328 DOI: 10.1152/japplphysiol.90563.2008] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Elastin is a major structural component of large elastic arteries and a principal determinant of arterial biomechanical properties. Elastin loss-of-function mutations in humans have been linked to the autosomal-dominant disease supravalvular aortic stenosis, which is characterized by stenotic lesions in both the systemic and pulmonary circulations. To better understand how elastin insufficiency influences the pulmonary circulation, we evaluated pulmonary cardiovascular physiology in a unique set of transgenic and knockout mice with graded vascular elastin dosage (range 45-120% of wild type). The central pulmonary arteries of elastin-insufficient mice had smaller internal diameters (P < 0.0001), thinner walls (P = 0.002), and increased opening angles (P = 0.002) compared with wild-type controls. Pulmonary circulatory pressures, measured by right ventricular catheterization, were significantly elevated in elastin-insufficient mice (P < 0.0001) and showed an inverse correlation with elastin level. Although elastin-insufficient animals exhibited mild to moderate right ventricular hypertrophy (P = 0.0001) and intrapulmonary vascular remodeling, the changes were less than expected, given the high right ventricular pressures, and were attenuated compared with those seen in hypoxia-induced models of pulmonary arterial hypertension. The absence of extensive pathological cardiac remodeling at the high pressures in these animals suggests a developmental adaptation designed to maintain right-sided cardiac output in a vascular system with altered elastin content.
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Affiliation(s)
- Adrian Shifren
- Department of Internal Medicine, Washington University School of Medicine, 660 S. Euclid, St. Louis, MO 63110, USA.
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28
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Lammers SR, Kao PH, Qi HJ, Hunter K, Lanning C, Albietz J, Hofmeister S, Mecham R, Stenmark KR, Shandas R. Changes in the structure-function relationship of elastin and its impact on the proximal pulmonary arterial mechanics of hypertensive calves. Am J Physiol Heart Circ Physiol 2008; 295:H1451-9. [PMID: 18660454 DOI: 10.1152/ajpheart.00127.2008] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Extracellular matrix remodeling has been proposed as one mechanism by which proximal pulmonary arteries stiffen during pulmonary arterial hypertension (PAH). Although some attention has been paid to the role of collagen and metallomatrix proteins in affecting vascular stiffness, much less work has been performed on changes in elastin structure-function relationships in PAH. Such work is warranted, given the importance of elastin as the structural protein primarily responsible for the passive elastic behavior of these conduit arteries. Here, we study structure-function relationships of fresh arterial tissue and purified arterial elastin from the main, left, and right pulmonary artery branches of normotensive and hypoxia-induced pulmonary hypertensive neonatal calves. PAH resulted in an average 81 and 72% increase in stiffness of fresh and digested tissue, respectively. Increase in stiffness appears most attributable to elevated elastic modulus, which increased 46 and 65%, respectively, for fresh and digested tissue. Comparison between fresh and digested tissues shows that, at 35% strain, a minimum of 48% of the arterial load is carried by elastin, and a minimum of 43% of the change in stiffness of arterial tissue is due to the change in elastin stiffness. Analysis of the stress-strain behavior revealed that PAH causes an increase in the strains associated with the physiological pressure range but had no effect on the strain of transition from elastin-dominant to collagen-dominant behavior. These results indicate that mechanobiological adaptations of the continuum and geometric properties of elastin, in response to PAH, significantly elevate the circumferential stiffness of proximal pulmonary arterial tissue.
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Affiliation(s)
- Steven R Lammers
- Mechanical Engineering, University of Colorado, Boulder, Colorado, USA
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Drexler ES. Stiffening of the Extrapulmonary Arteries From Rats in Chronic Hypoxic Pulmonary Hypertension. JOURNAL OF RESEARCH OF THE NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY 2008; 113:239-49. [PMID: 27096124 PMCID: PMC4651618 DOI: 10.6028/jres.113.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Indexed: 05/02/2023]
Abstract
Changes in the compliance properties of large blood vessels are critical determinants of ventricular afterload and ultimately dysfunction. Little is known of the mechanical properties of large vessels exhibiting pulmonary hypertension, particularly the trunk and right main artery. We initiated a study to investigate the influence of chronic hypoxic pulmonary hypertension on the mechanical properties of the extrapulmonary arteries of rats. One group of animals was housed at the equivalent of 5000 m elevation for three weeks and the other held at ambient conditions of ~1600 m. The two groups were matched in age and gender. The animals exposed to hypobaric hypoxia exhibited signs of pulmonary hypertension, as evidenced by an increase in the RV/(LV+S) heart weight ratio. The extrapulmonary arteries of the hypoxic animals were also thicker than those of the control population. Histological examination revealed increased thickness of the media and additional deposits of collagen in the adventitia. The mechanical properties of the trunk, and the right and left main pulmonary arteries were assessed; at a representative pressure (7 kPa), the two populations exhibited different quantities of stretch for each section. At higher pressures we noted less deformation among the arteries from hypoxic animals as compared with controls. A four-parameter constitutive model was employed to fit and analyze the data. We conclude that chronic hypoxic pulmonary hypertension is associated with a stiffening of all the extrapulmonary arteries.
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Celermajer DS, Marwick T. Echocardiographic and right heart catheterization techniques in patients with pulmonary arterial hypertension. Int J Cardiol 2008; 125:294-303. [PMID: 17689753 DOI: 10.1016/j.ijcard.2007.04.184] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Accepted: 04/23/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND The cardiovascular assessment of patients with suspected pulmonary arterial hypertension (PAH) involves Doppler echocardiography and often subsequent confirmation by right heart catheterization (RHC). However, there appears to be limited consensus on the appropriate technique(s) for assessing PAH, and thus no clear, comprehensive guidelines exist for assessment of PAH. The aim of this paper is to review the Doppler echocardiographic and RHC techniques for the diagnosis and/or assessment of PAH. METHOD We searched Medline (1966 to August 2006) and EMBASE (1980 to August 2006) bibliographic databases to allow identification of all potentially relevant studies and review articles. In addition, the reference lists of included articles were scanned to identify relevant references and unpublished reports missed by the search strategy. RESULTS Our findings show that recommendations for the echocardiographic assessment of PAH at rest or with exercise are heterogeneous. Clinical practice guidelines provide limited details. Although more specific information regarding echocardiographic techniques can be obtained from individual research articles, the techniques employed and the methods used to calculate specific hemodynamic variables do not appear to be consistent throughout the literature. RHC techniques for the confirmation of PAH are more consistent, albeit less frequently reported. The literature search identified several articles where indications and considerations for the catheterization of patients with PAH are discussed, together with safety considerations and principles for the accurate assessment of hemodynamic variables. CONCLUSION Although clinical practice guidelines and numerous research studies provide details of echocardiographic measures in patients with PAH, greater consensus and standardisation of measurement techniques is required. A minimum dataset for the evaluation of PAH by these techniques is suggested.
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Affiliation(s)
- David S Celermajer
- Royal Prince Alfred Hospital and the University of Sydney, Sydney, NSW, Australia
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Hunter KS, Gross JK, Lanning CJ, Kirby KS, Dyer KL, Ivy DD, Shandas R. Noninvasive methods for determining pulmonary vascular function in children with pulmonary arterial hypertension: application of a mechanical oscillator model. CONGENIT HEART DIS 2008; 3:106-16. [PMID: 18380759 PMCID: PMC3116924 DOI: 10.1111/j.1747-0803.2008.00172.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Noninvasive diagnostics for pulmonary arterial hypertension (PAH) have traditionally sought to predict main pulmonary artery pressure from qualitative or direct quantitative measures of the flow velocity pattern obtained from spectral Doppler ultrasound examination of the main pulmonary artery. A more detailed quantification of flow velocity patterns in the systemic circuit has been obtained by parameterizing the flow trace with a simple dynamic system model. Here, we investigate such a model's utility as a noninvasive predictor of total right heart afterload and right heart function. DESIGN Flow velocity and pressure was measured within the main pulmonary artery during right heart catheterization of patients with normal hemodynamics (19 subjects, 20 conditions) and those with PAH undergoing reactivity evaluation (34 patients, 69 conditions). Our model parameters were obtained by least-squares fitting the model velocity to the measured flow velocity. RESULTS Five parameter means displayed significant (P < .05) differences between normotensive and hypertensive groups. The model stiffness parameter correlated to actual pulmonary vascular resistance (r = 0.4924), pulmonary vascular stiffness (r = 0.6811), pulmonary flow (r = 0.6963), and stroke work (r = 0.7017), while the model initial displacement parameter had good correlation to stiffness (r = 0.6943) and flow (r = 0.6958). CONCLUSIONS As predictors of total right heart afterload (resistance and stiffness) and right ventricle work, the model parameters of stiffness and initial displacement offer more comprehensive measures of the disease state than previous noninvasive methods and may be useful in routine diagnostic monitoring of patients with PAH.
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Affiliation(s)
- Kendall S Hunter
- Center for Bioengineering, University of Colorado Health Science Center, Denver, CO 80045, USA.
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Hunter KS, Lee PF, Lanning CJ, Ivy DD, Kirby KS, Claussen LR, Chan KC, Shandas R. Pulmonary vascular input impedance is a combined measure of pulmonary vascular resistance and stiffness and predicts clinical outcomes better than pulmonary vascular resistance alone in pediatric patients with pulmonary hypertension. Am Heart J 2008; 155:166-74. [PMID: 18082509 PMCID: PMC3139982 DOI: 10.1016/j.ahj.2007.08.014] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Accepted: 08/12/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Pulmonary vascular resistance (PVR) is the current standard for evaluating reactivity in children with pulmonary arterial hypertension (PAH). However, PVR measures only the mean component of right ventricular afterload and neglects pulsatile effects. We recently developed and validated a method to measure pulmonary vascular input impedance, which revealed excellent correlation between the zero harmonic impedance value and PVR and suggested a correlation between higher-harmonic impedance values and pulmonary vascular stiffness. Here we show that input impedance can be measured routinely and easily in the catheterization laboratory, that impedance provides PVR and pulmonary vascular stiffness from a single measurement, and that impedance is a better predictor of disease outcomes compared with PVR. METHODS Pressure and velocity waveforms within the main pulmonary artery were measured during right heart catheterization of patients with normal pulmonary artery hemodynamics (n = 14) and those with PAH undergoing reactivity evaluation (49 subjects, 95 conditions). A correction factor needed to transform velocity into flow was obtained by calibrating against cardiac output. Input impedance was obtained off-line by dividing Fourier-transformed pressure and flow waveforms. RESULTS Exceptional correlation was found between the indexed zero harmonic of impedance and indexed PVR (y = 1.095x + 1.381, R2 = 0.9620). In addition, the modulus sum of the first 2 harmonics of impedance was found to best correlate with indexed pulse pressure over stroke volume (y = 13.39x - 0.8058, R2 = 0.7962). Among a subset of patients with PAH (n = 25), cumulative logistic regression between outcomes to total indexed impedance was better (R(L)2 = 0.4012) than between outcomes and indexed PVR (R(L)2 = 0.3131). CONCLUSIONS Input impedance can be consistently and easily obtained from pulse-wave Doppler and a single catheter pressure measurement, provides comprehensive characterization of the main components of RV afterload, and better predicts patient outcomes compared with PVR alone.
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Affiliation(s)
- Kendall S. Hunter
- Department of Pediatric Cardiology, University of Colorado Health Sciences Center, 1056 E. 19 Ave, Denver, CO 80218
| | - Po-Feng Lee
- Department of Bioengineering, Texas A&M University, College Station, TX 77843
| | - Craig J. Lanning
- Department of Pediatric Cardiology, University of Colorado Health Sciences Center, 1056 E. 19 Ave, Denver, CO 80218
| | - D. Dunbar Ivy
- Department of Pediatric Cardiology, University of Colorado Health Sciences Center, 1056 E. 19 Ave, Denver, CO 80218
| | - K. Scott Kirby
- Department of Pediatric Cardiology, University of Colorado Health Sciences Center, 1056 E. 19 Ave, Denver, CO 80218
| | - Lori R. Claussen
- Department of Pediatric Cardiology, University of Colorado Health Sciences Center, 1056 E. 19 Ave, Denver, CO 80218
| | - K. Chen Chan
- Department of Pediatric Cardiology, University of Colorado Health Sciences Center, 1056 E. 19 Ave, Denver, CO 80218
| | - Robin Shandas
- Department of Pediatric Cardiology, University of Colorado Health Sciences Center, 1056 E. 19 Ave, Denver, CO 80218
- Department of Mechanical Engineering, University of Colorado at Boulder, Boulder, CO 80309-0427
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Gan CTJ, Lankhaar JW, Westerhof N, Marcus JT, Becker A, Twisk JWR, Boonstra A, Postmus PE, Vonk-Noordegraaf A. Noninvasively assessed pulmonary artery stiffness predicts mortality in pulmonary arterial hypertension. Chest 2007; 132:1906-12. [PMID: 17989161 DOI: 10.1378/chest.07-1246] [Citation(s) in RCA: 301] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
AIMS Decreased total compliance of the pulmonary vascular bed is associated with increased mortality in patients with pulmonary arterial hypertension (PAH). We investigated whether proximal pulmonary artery stiffness, in terms of area distensibility and noninvasively assessed relative area change (RAC), calculated as relative cross-sectional area change, predicts mortality in patients with PAH. METHODS AND RESULTS Eighty-six subjects underwent right-heart catheterization and MRI to assess area distensibility and RAC. Patients were followed up to 48 months. Kaplan-Meier plot and Cox proportional hazards regression analyses assessed the predictive value of area distensibility and RAC. In 70 patients, the diagnosis PAH was confirmed, and 16 subjects served as control subjects. In comparison with control subjects, proximal pulmonary arteries of patients were distended (685 +/- 214 mm2 vs 411 +/- 153 mm2, p < 0.001), less distensible (area distensibility = 0.46 +/- 0.38.10(-2) mm Hg(-1) vs 3.69 +/- 1.96.10(-2) mm Hg(-1), p < 0.0001), and RAC was smaller (20 +/- 10% vs 58 +/- 21%, p < 0.0001) [mean +/- SD]. RAC showed an inverse curvilinear relation with mean pulmonary artery pressure (R2 = 0.47). Eighteen patients (26%) died because of cardiopulmonary causes. Patients with a pulmonary artery RAC <or= 16% had a worse prognosis than those with a value > 16% (log-rank p < 0.001). RAC predicted mortality better than area distensibility. CONCLUSION Noninvasively measured pulmonary artery RAC predicts mortality in patients with PAH.
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Affiliation(s)
- C Tji-Joong Gan
- Department of Pulmonary Diseases, VU University Medical Center, De Boelelaan 1117, PO Box 7057, 1007 MB Amsterdam, the Netherlands
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Zhang Y, Dunn ML, Hunter KS, Lanning C, Ivy DD, Claussen L, Chen SJ, Shandas R. Application of a microstructural constitutive model of the pulmonary artery to patient-specific studies: validation and effect of orthotropy. J Biomech Eng 2007; 129:193-201. [PMID: 17408324 PMCID: PMC3114451 DOI: 10.1115/1.2485780] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We applied a statistical mechanics based microstructural model of pulmonary artery mechanics, developed from our previous studies of rats with pulmonary arterial hypertension (PAH), to patient-specific clinical studies of children with PAH. Our previous animal studies provoked the hypothesis that increased cross-linking density of the molecular chains may be one biological remodeling mechanism by which the PA stiffens in PAH. This study appears to further confirm this hypothesis since varying molecular cross-linking density in the model allows us to simulate the changes in the P-D loops between normotensive and hypertensive conditions reasonably well. The model was combined with patient-specific three-dimensional vascular anatomy to obtain detailed information on the topography of stresses and strains within the proximal branches of the pulmonary vasculature. The effect of orthotropy on stressstrain within the main and branch PAs obtained from a patient was explored. This initial study also puts forward important questions that need to be considered before combining the microstructural model with complex patient-specific vascular geometries.
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Affiliation(s)
- Yanhang Zhang
- Department of Aerospace and Mechanical Engineering, Boston University, Boston, MA 02215, USA
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Forfia PR, Fisher MR, Mathai SC, Housten-Harris T, Hemnes AR, Borlaug BA, Chamera E, Corretti MC, Champion HC, Abraham TP, Girgis RE, Hassoun PM. Tricuspid annular displacement predicts survival in pulmonary hypertension. Am J Respir Crit Care Med 2006; 174:1034-41. [PMID: 16888289 DOI: 10.1164/rccm.200604-547oc] [Citation(s) in RCA: 744] [Impact Index Per Article: 39.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
RATIONALE Right ventricular (RV) function is an important determinant of prognosis in pulmonary hypertension. However, noninvasive assessment of the RV function is often limited by complex geometry and poor endocardial definition. OBJECTIVES To test whether the degree of tricuspid annular displacement (tricuspid annular plane systolic excursion [TAPSE]) is a useful echo-derived measure of RV function with prognostic significance in pulmonary hypertension. METHODS We prospectively studied 63 consecutive patients with pulmonary hypertension who were referred for a clinically indicated right heart catheterization. Patients underwent right heart catheterization immediately followed by transthoracic echocardiogram and TAPSE measurement. RESULTS In the overall cohort, a TAPSE of less than 1.8 cm was associated with greater RV systolic dysfunction (cardiac index, 1.9 vs. 2.7 L/min/m2; RV % area change, 24 vs. 33%), right heart remodeling (right atrial area index, 17.0 vs. 12.1 cm(2)/m), and RV-left ventricular (LV) disproportion (RV/LV diastolic area, 1.7 vs. 1.2; all p < 0.001), versus a TAPSE of 1.8 cm or greater. In patients with pulmonary arterial hypertension (PAH; n = 47), survival estimates at 1 and 2 yr were 94 and 88%, respectively, in those with a TAPSE of 1.8 cm or greater versus 60 and 50%, respectively, in subjects with a TAPSE less than 1.8 cm. The unadjusted risk of death (hazard ratio) in patients with a TAPSE less than 1.8 versus 1.8 cm or greater was 5.7 (95% confidence interval, 1.3-24.9; p = 0.02) for the PAH cohort. For every 1-mm decrease in TAPSE, the unadjusted risk of death increased by 17% (hazard ratio, 1.17; 95% confidence interval, 1.05-1.30; p = 0.006), which persisted after adjusting for other echocardiographic and hemodynamic variables and baseline treatment status. CONCLUSIONS TAPSE powerfully reflects RV function and prognosis in PAH.
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Affiliation(s)
- Paul R Forfia
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Asthma & Allergy Center, Baltimore, MD 21224, USA
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