Pulmonary arterial hypertension in congenital heart disease: translational opportunities to study the reversibility of pulmonary vascular disease

Long-term survival of shunt closure in atrial septal defects with pulmonary arterial hypertension

OBJECTIVE

This study aims to refine closure indications and assess long-term outcomes in pulmonary arterial hypertension associated with atrial septal defect (PAH-ASD).

METHODS

We enrolled 197 PAH-ASD patients classified as unrepairable (n = 101) or repairable (n = 96), with the latter subdivided into direct repair (DR, n = 74) and treat-and-repair (TR, n = 22) groups. Closure criteria included pulmonary vascular resistance (PVR) 3-6 Wood units and Qp/Qs ≥1.5. The TR group received targeted therapy before closure.

RESULTS

Targeted therapy significantly improved TR group hemodynamics: PVR decreased from 8.0 ± 2.0 to 3.0 ± 1.0 WU (p < 0.001); Qp/Qs increased from 1.7 ± 0.4 to 2.3 ± 0.3 (p < 0.001). Post-closure, pulmonary artery systolic pressure significantly decreased in both TR (67 ± 15 to 38 ± 9 mmHg) and DR groups (66 ± 17 to 40 ± 10 mmHg) (both p < 0.001). Right ventricular remodeling improved significantly. During median follow-up (3.7-4.5 years), mortality was lower in repairable versus unrepairable groups (1 vs. 10 deaths). Univariate COX analysis identified ASD closure as a protective factor (HR 0.093, 95 %CI [0.01,0.98].

CONCLUSION

ASD closure improves long-term survival in select PAH-ASD patients. Targeted therapy enables closure in previously ineligible patients.

The Challenge in Burden of Pulmonary Arterial Hypertension: A Perspective From the Global Burden of Disease Study

Pulmonary arterial hypertension (PAH) poses significant clinical management challenges due to gaps in understanding its global epidemiology. We analyzed PAH-related disability-adjusted life years (DALYs), deaths, and prevalence from 1990 to 2021. Age-period-cohort models and regression analyses assessed temporal trends and projected burdens to 2050. Globally, PAH-related DALYs declined by 6.6%, but increased by 13.9% in high socio-demographic index (SDI) countries. Middle SDI regions reported the highest DALYs in 1990 and 2021. Deaths rose by 48.5% worldwide, with high SDI nations experiencing a 76.6% surge. Age-standardized rates (ASRs) of DALYs and deaths decreased across SDI countries, with high-middle SDI regions showing the steepest declines. Younger age groups, especially males, had a higher proportion of global DALYs in earlier years, but the burden shifted toward older populations over time, with this trend more pronounced in high-SDI countries. Age-period-cohort analysis revealed declining DALYs in younger ages but rising rates in older cohorts. By 2050, deaths and prevalence are projected to rise, disproportionately affecting females. Significant regional disparities in PAH burden persist, necessitating targeted policies, improved healthcare access, and early detection strategies, especially in underserved areas. Addressing these disparities is critical for mitigating PAH' s global impact.

Follow-up of transcatheter closure of congenital heart disease complicated with pulmonary arterial hypertension in children

Background

Transcatheter closure is now the preferred treatment for congenital heart disease complicated with pulmonary arterial hypertension (CHD-PAH), but its long-term effects are not well understood. We aimed to assess the safety, effectiveness, and outcome of this procedure in children with CHD-PAH.

Methods

We included 210 children with CHD-PAH at our hospital from 2012 to 2021 and collected their general, laboratory, echocardiographic, and hemodynamic data for analysis. A logistic regression analysis identified risk factors for persistent postclosure PAH (PP-PAH).

Results

Among the 210 patients, 84.29% had mild PAH, 8.57% had moderate PAH, and 7.14% had severe PAH. The device was successfully implanted in 98.10% of patients. Early adverse events occurred in 12.14% (n = 25) of patients, with residual shunts and arrhythmia being the most common complications, each affecting 2.91% (n = 6) of patients. Most complications were minor and temporary, except for two cases of residual shunt-one required surgical repair, and one case of complete left bundle branch block led to occluder removal. Postintervention, pulmonary arterial pressure (PAP) decreased significantly, and cardiomegaly resolved. PP-PAH was detected in 13 patients (6.31%). Preoperative pulmonary arterial systolic pressure [odds ratio [OR] = 1.033, 95% confidence interval [CI] = 1.005-1.061, P = 0.019] and right ventricular diameter (OR = 1.111, 95% CI = 1.039-1.187, P = 0.002) were found to be risk factors for PP-PAH.

Conclusion

Transcatheter closure is effective and safe for children with correctable CHD-PAH. Preoperative pulmonary arterial systolic pressure and right ventricular diameter are risk factors for PP-PAH.

Management of pulmonary vascular disease associated with congenital left-to-right shunts: A single-center experience

OBJECTIVE

The study objective was to describe the course and outcomes of children under 18 years of age, with left-to-right shunts and pulmonary arterial hypertension undergoing 1 of 2 management approaches: pulmonary arterial hypertension treatment before left-to-right shunt repair (Treat First) and left-to-right shunt repair first with or without subsequent pulmonary arterial hypertension treatment (Repair First).

METHODS

We performed a retrospective single-center study, conducted from September 2015 to September 2021, of children with left-to-right shunts and pulmonary arterial hypertension (defined as indexed pulmonary vascular resistance ≥ 4 Wood units [WU]∗m2) but without Eisenmenger physiology. Patient characteristics, longitudinal hemodynamics data, pulmonary arterial hypertension management, left-to-right shunt repair, and outcomes were reviewed.

RESULTS

Of 768 patients evaluated for left-to-right shunt closure, 51 (6.8%) had left-to-right shunts associated with pulmonary arterial hypertension (median age 1.1 [0.37-5] years, median indexed pulmonary vascular resistance 6 [5.2-8.7] WU∗m2). In the "Treat First" group (n = 33, 65%), 27 patients (82%) underwent left-to-right shunt closure and 6 patients (18%) did not respond to pulmonary arterial hypertension therapy and did not undergo left-to-right shunt closure. In the "Repair First" group (n = 18, 35%), 12 patients (67%) received pulmonary arterial hypertension therapy and 6 patients (33%) did not. Mortality rates were 6% in the "Treat First" group and 11% in "Repair First" group with follow-ups of 3.4 and 2.5 years, respectively. After left-to-right shunt closure, there was no significant change in indexed pulmonary vascular resistance over a median follow-up of 2 years after surgery (P = .77).

CONCLUSIONS

In children with left-to-right shunts and associated pulmonary arterial hypertension, treatment with pulmonary arterial hypertension-targeted therapy before defect repair does not appear to endanger the subjects and may have some benefit. The response to pulmonary arterial hypertension-targeted therapy before shunt closure persists 2 to 3 years postclosure, providing valuable insights into the long-term management of these patients.

Independent prognostic value of lipocalin-2 in congenital heart disease-associated pulmonary artery hypertension

BACKGROUND

Timely and accurate evaluation of the patient's pulmonary arterial pressure (PAP) is of great significance for the treatment of congenital heart disease. Currently, there is no non-invasive gold standard method for evaluating PAP.

AIM

To assess the prognostic value of lipocalin-2 (LCN2) in relation to PAP in patients with congenital heart disease associated with pulmonary artery hypertension.

METHODS

We conducted a retrospective analysis of 69 pediatric patients diagnosed with ventricular septal defects. The patients' clinical and laboratory data were collected. The serum LCN2 concentrations were compared between the pulmonary arterial hypertension (PAH) group and the nonPAH group. The correlation of LCN2 concentration with PAH classification was evaluated using binary logistic regression analysis. The receiver operating characteristic (ROC) curve was used to evaluate the diagnostic potential of LCN2 for PAH.

RESULTS

Serum LCN2 concentration significantly correlated with patients' mean PAP (r = 0.544, P < 0.001), but not correlated with creatinine (P = 0.446) or blood urea nitrogen (P = 0.747). LCN2 levels were significantly correlated with PAH in both univariate [odds ratio (OR) 1.107, 95%CI: 1.033-1.185, P = 0.004)] and multivariate regression analysis (OR 1.150, 95%CI: 1.027-1.288, P = 0.015). ROC curve analysis revealed an area under the curve of 0.783 for LCN2. At the cutoff value of 19.42 ng/mL, the sensitivity and specificity of LCN2 for diagnosing PAH is 90.19% and 55.56%, respectively. LCN2 concentration also significantly correlated with the post-repair mean PAP in patients with congenital heart disease (r = 0.532, P = 0.009).

CONCLUSION

LCN2 is emerging as a candidate biomarker for assessing PAP in patients with congenital heart disease. Its high sensitivity in diagnosing PAH makes it a valuable tool in patient management.

Case report: Cilioretinal artery occlusion combined with central retinal vein occlusion as the initial presentation of pulmonary arterial hypertension

Background

Pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary artery pressure and vascular resistance, leading to systemic venous hypertension and potential right heart failure. These elevated pressures can extend to ocular veins, resulting in complications such as central retinal vein occlusion (CRVO). This case report highlights a rare instance of CRVO combined with cilioretinal artery occlusion (CilRAO), an uncommon ocular manifestation associated with PAH.

Case presentation

A 13-year-old girl with a history of surgically repaired ventricular septal defect presented with sudden vision loss and a central visual field defect. Investigation confirmed CRVO and an unusual concurrent CilRAO. Although laboratory tests were inconclusive, the echocardiographic examination suggested severe pulmonary arterial hypertension (PAH). The patient received treatment with Bosentan and traditional Chinese medicine, which improved her vision to 20/20, though a paracentral scotoma remained.

Conclusion

This case underscores the critical link between systemic cardiovascular abnormalities and ocular health in PAH, where elevated venous pressure can result in severe and distinctive ocular manifestations. The co-occurrence of CRVO and CilRAO in this patient highlights the susceptibility of cilioretinal arteries to hemodynamic changes, as these arteries lack autoregulatory capacity. Additionally, this case demonstrates the potential for positive outcomes in ocular lesions with targeted PAH therapy. Importantly, it emphasizes the need for vigilance when managing complex cases where conclusions cannot be drawn solely from ocular findings. A multidisciplinary approach and comprehensive diagnostics are essential for identifying underlying causes, ensuring active treatment, and preventing permanent vision loss and serious systemic complications.

Nucleic acid liquid biopsies in cardiovascular disease: Cell-free DNA liquid biopsies in cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of death worldwide, and despite treatment efforts, cardiovascular function cannot always be restored, and progression of disease be prevented. Critical insights are oftentimes based on tissue samples. Current knowledge of tissue pathology typically relies on invasive biopsies or postmortem samples. Liquid biopsies, which assess circulating mediators to deduce the histology and pathology of distant tissues, have been advancing rapidly in cancer research and offer a promising approach to be translated to the understanding and treatment of CVD. The widely understood elevations in cell-free DNA during acute and chronic cardiovascular conditions, associate with disease, severity, and offer prognostic value. The role of neutrophil extracellular traps (NETs) and circulating nucleases in thrombosis provide a solid rationale for liquid biopsies in CVD. cfDNA originates from various tissue types and cellular sources, including mitochondria and nuclei, and can be used to trace cell and tissue type lineage, as well as to gain insight into the activation status of cells. This article discusses the origin, structure, and potential utility of cfDNA, offering a deeper and less invasive approach for the understanding of the complexities of CVD.

Circulating High Mobility Group Box-1 Does Not Predict Pulmonary Arterial Hypertension in Children with Congenital Heart Disease: A Prospective Cohort Study

OBJECTIVES

Pulmonary arterial hypertension (PAH) is a devastating complication of pediatric congenital heart disease (CHD). A recent study has identified the protein high mobility group box-1 (HMGB1) as a diagnostic tool in adults with CHD-associated PAH. HMGB1 levels in adults with CHD-associated PAH correlated with mean pulmonary artery pressure and pulmonary vascular resistance, and HGMB1 levels fell in response to sildenafil therapy. We wanted to assess if HGMB1 was a biomarker of pediatric CHD-PAH.

DESIGN

Prospective cohort study.

SETTING

Quaternary pediatric academic hospital PARTICIPANTS: Children ≤18 years with CHD with and without known pulmonary hypertension. Controls were children undergoing dental or urologic surgery with no known heart disease.

INTERVENTIONS

Pulmonary hemodynamics, echocardiographic assessment, and biomarker measurement. Controls had biomarker measurement only.

MEASUREMENTS AND MAIN RESULTS

Patients with CHD-PAH had mean pulmonary vascular resistance index of 10 Wood units/m2. Neither HGMB1 nor N-terminal pro-brain-type natriuretic peptide levels were significantly different between the groups. Neither marker correlated with pulmonary hypertension.

CONCLUSIONS

Unlike in adults, HGMB1 is not a biomarker of PAH in pediatric CHD. Further work will continue to explore for biomarkers for this high-risk population.

Smooth muscle Cxcl12 activation is associated with vascular remodeling in flow-induced pulmonary hypertension

Patients with congenital heart disease (CHD) resulting in significant left-to-right shunting of blood are at risk for the development of pulmonary arterial hypertension (PAH). The underlying mechanism by which pulmonary overcirculation and shear stress lead to vascular remodeling remains unclear. Our study established a new "two-hit" murine model of severe pulmonary hypertension (PH) by combining left pneumonectomy and exposure to hypoxia (LP/Hx). Utilizing transgenic reporter lines, immunofluorescence staining, and advanced microscopy, we conducted cell-lineage tracing experiments for endothelial cells (ECs), smooth muscle cells (SMCs), and pericytes. We identified that SMCs is a primary contributor to distal arteriolar remodeling after LP/Hx. Subsequent qPCR analysis on isolated cells demonstrated that Cxcl12 was upregulated in both ECs and SMCs from LP/Hx animals. Likewise, CXCL12 was overexpressed in the SMC layer of arterioles in patients with acyanotic PAH-CHD. These findings provide novel insights into the contribution of SMCs and Cxcl12 to pulmonary flow-induced vascular remodeling. This newly established murine model of PH will serve as a new tool for research and targeted therapeutics for patients with PAH.

Cellular senescence in the pathogenesis of pulmonary arterial hypertension: the good, the bad and the uncertain

Senescence refers to a cellular state marked by irreversible cell cycle arrest and the secretion of pro-inflammatory and tissue-remodeling factors. The senescence associated secretory phenotype (SASP) impacts the tissue microenvironment and provides cues for the immune system to eliminate senescent cells (SCs). Cellular senescence has a dual nature; it can be beneficial during embryonic development, tissue repair, and tumor suppression, but it can also be detrimental in the context of chronic stress, persistent tissue injury, together with an impairment in SC clearance. Recently, the accumulation of SCs has been implicated in the pathogenesis of pulmonary arterial hypertension (PAH), a progressive condition affecting the pre-capillary pulmonary arterial bed. PAH is characterized by endothelial cell (EC) injury, inflammation, and proliferative arterial remodeling, which leads to right heart failure and premature mortality. While vasodilator therapies can improve symptoms, there are currently no approved treatments capable of reversing the obliterative arterial remodeling. Ongoing endothelial injury and dysfunction is central to the development of PAH, perpetuated by hemodynamic perturbation leading to pathological intimal shear stress. The precise role of senescent ECs in PAH remains unclear. Cellular senescence may facilitate endothelial repair, particularly in the early stages of disease. However, in more advanced disease the accumulation of senescent ECs may promote vascular inflammation and occlusive arterial remodeling. In this review, we will examine the evidence that supports a role of endothelial cell senescence to the pathogenesis of PAH. Furthermore, we will compare and discuss the apparent contradictory outcomes with the use of interventions targeting cellular senescence in the context of experimental models of pulmonary hypertension. Finally, we will attempt to propose a framework for the understanding of the complex interplay between EC injury, senescence, inflammation and arterial remodeling, which can guide further research in this area and the development of effective therapeutic strategies.

Right ventricular fibrosis in adults with uncorrected secundum atrial septal defect and pulmonary hypertension: a cardiovascular magnetic resonance study with late gadolinium enhancement, native T1 and extracellular volume

Introduction

Right ventricular (RV) fibrosis represents both adaptive and maladaptive responses to the overloaded RV condition. Its role in pulmonary hypertension (PH) associated with secundum atrial septal defect (ASD), which is the most common adult congenital heart disease (CHD), remains poorly understood.

Methods

We enrolled 65 participants aged ≥18 years old with uncorrected secundum ASD who had undergone clinically indicated right heart catheterization (RHC), divided into the non-PH group (n = 7), PH group (n = 42), and Eisenmenger syndrome (ES) group (n = 16). We conducted cardiovascular magnetic resonance (CMR) studies with late gadolinium enhancement (LGE) imaging, native T1 mapping, and extracellular volume (ECV) measurement to evaluate the extent and clinical correlates of RV fibrosis.

Results

LGE was present in 94% of the population and 86% of the non-PH group, mostly located at the right ventricular insertion point (RVIP) regions. LGE in the septal and inferior RV region was predominantly observed in the ES group compared to the other groups (p = 0.031 and p < 0.001, respectively). The mean LGE scores in the ES and PH groups were significantly higher than those in the non-PH group (3.38 ± 0.96 vs. 2.74 ± 1.04 vs. 1.57 ± 0.79; p = 0.001). The ES and PH groups had significantly higher degrees of interstitial RV fibrosis compared to those in the non-PH group, indicated by native T1 (1,199.9 ± 68.9 ms vs. 1,131.4 ± 47.8 ms vs. 1,105.4 ± 44.0 ms; p < 0.001) and ECV (43.6 ± 6.6% vs. 39.5 ± 4.9% vs. 39.4 ± 5.8%; p = 0.037). Additionally, native T1 significantly correlated with pulmonary vascular resistance (r = 0.708, p < 0.001), RV ejection fraction (r = -0.468, p < 0.001) and peripheral oxygen saturation (r = -0.410, p = 0.001).

Conclusion

In patients with uncorrected secundum ASD, RV fibrosis may occur before the development of PH and progressively intensify alongside the progression of PH severity. A higher degree of RV fibrosis, derived from CMR imaging, correlates with worse hemodynamics, RV dysfunction, and poorer clinical conditions.

Prevalence and influence of pulmonary hypertension in patients with obstructive hypertrophic cardiomyopathy undergoing septal myectomy

OBJECTIVES

Pulmonary hypertension (PH) is an independent predictor of all-cause mortality among patients with obstructive and nonobstructive hypertrophic cardiomyopathy (HCM). However, there is little information on the influence of coexisting PH on long-term survival following septal myectomy. This study investigates the prevalence of PH among patients with obstructive HCM undergoing septal myectomy and analyzes patient survival and the course of PH after operation.

METHODS

We included 1342 patients with obstructive HCM who had Doppler echocardiographic estimates of the right ventricular systolic pressure (RVSP) before and after transaortic septal myectomy. PH was defined as RVSP ≥35 mm Hg, with ≥50 mm Hg categorized as moderate-to-severe PH. A multivariable Cox proportional hazards model was used to identify characteristics associated with survival, and longitudinal trends in RVSP were modeled with generalized least squares analysis.

RESULTS

Patients underwent operations from 1989 to 2019. The median age was 57.9 years (interquartile range, 47.4-66.7 years); 49.5% were women. Preoperatively, PH was present in 47.8% of patients, and 14.4% had moderate-to-severe PH. Higher preoperative RVSP was independently associated with overall mortality in the multivariable Cox model. Among patients with moderate to severe preoperative RVSP elevation, postoperative RVSP decreased from baseline by a median of 12 mm Hg.

CONCLUSIONS

Preoperative PH is independently associated with late mortality following septal myectomy, and the magnitude of preoperative RVSP was associated with a postoperative decrease in pulmonary pressure. The influence of PH on late postoperative survival may influence the timing of operation in patients who are candidates for septal myectomy.

Demographic, hemodynamic characteristics, and therapeutic trends of pulmonary hypertension patients: The Pulmonary Hypertension Mexican registry (REMEHIP)

Data on demographic characteristics and therapeutic approaches in Latin American pulmonary arterial hypertension (PAH) patients are scarce. Pulmonary Hypertension Mexican registry (REMEHIP) is a multicenter Mexican registry of adult and pediatric patients, including prevalent and incident cases. Objective: assess clinical characteristics, treatment trends, and in-hospital outcomes. Inclusion: age >2 years, diagnosis of pulmonary hypertension (PH) (groups 1 and 4), right heart catheterization with mPAP ≥25 mmHg, PWP ≤ 15 mmHg, and PVR > 3 Wood unit (WU). We included 875 PH patients, 619 adults, 133 pediatric idiopathic PAH (IPAH), and 123 chronic thromboembolic pulmonary hypertension (CTEPH) patients. We enrolled 48.4% of the incident and 51.6% of the prevalent adult and pediatric patients. PAH adults: age 43 ± 15, females 81.9%, functional class (FC) (I/II) 66.5%, 6-min walk distance (6MWD) 378 ± 112 m, mPAP 57.3 ± 19.0 mmHg, confidence interval (CI) 3.3 ± 1.5 L/min/m2, PVR 12.0 ± 8.1 WU. PAH pediatrics: age 9 ± 5, females 51.1%, FC (I/II) 85.5%, 6MWD 376 ± 103 m, mPAP 49.7 ± 13.4 mmHg, CI 2.6 ± 0.9 L/min/m2, PVR 16.4 ± 13.5 WU. CTEPH: age 44 ± 17, females 56.1%, FC (I/II) 65.5%, 6MWD 369 ± 126 m, mPAP 49.7 ± 13.4 mmHg, CI 2.6 ± 0.9 L/min/m2, PVR 10.5 + 6.5 WU. When we analyzed the IPAH group separately, it sustained a high functional class I/II incidence. REMEHIP shows better functional class in young females with severe PAH than in American and European patients. Also, PAH pediatric patients had a better functional class than other registries. However, our registry also shows that our population's access to specific pharmacologic treatments is still far from optimal.

Simvastatin restores pulmonary endothelial function in the setting of pulmonary over-circulation

Statin therapy is a cornerstone in the treatment of systemic vascular diseases. However, statins have failed to translate as therapeutics for pulmonary vascular disease. Early pulmonary vascular disease in the setting of congenital heart disease (CHD) is characterized by endothelial dysfunction, which precedes the more advanced stages of vascular remodeling. These features make CHD an ideal cohort in which to re-evaluate the potential pulmonary vascular benefits of statins, with a focus on endothelial biology. However, it is critical that the full gamut of the pleiotropic effects of statins in the endothelium are uncovered. The purpose of this investigation was to evaluate the therapeutic potential of simvastatin for children with CHD and pulmonary over-circulation, and examine mechanisms of simvastatin action on the endothelium. Our data demonstrate that daily simvastatin treatment preserves endothelial function in our shunt lamb model of pulmonary over-circulation. Further, using pulmonary arterial endothelial cells (PAECs) isolated from Shunt and control lambs, we identified a new mechanism of statin action mediated by increased expression of the endogenous Akt1 inhibitor, C-terminal modifying protein (CTMP). Increases in CTMP were able to decrease the Akt1-mediated mitochondrial redistribution of endothelial nitric oxide synthase (eNOS) which correlated with increased enzymatic coupling, identified by increases in NO generation and decreases in NOS-derived superoxide. Together our data identify a new mechanism by which simvastatin enhances NO signaling in the pulmonary endothelium and identify CTMP as a potential therapeutic target to prevent the endothelial dysfunction that occurs in children born with CHD resulting in pulmonary over-circulation.

Prognostic Implication of Pulmonary Arterial Pressure in Surgical Repair of Predominantly Congenital Mitral Valve Regurgitation-Based Intracardiac Abnormalities

INTRODUCTION

Knowledge is limited regarding the significance of pulmonary arterial pressure (PAP) in predominantly congenital mitral valve regurgitation (MR)-based intracardiac abnormalities.

METHODS

From a prospective cohort, we included 200 patients with congenital MR regardless of other associated intracardiac abnormalities (mean age 60.4 months, 67% female, systolic PAP (sPAP) 54.2 mm Hg) surgically repaired in 2012-2019 and followed up to 2020 (median 30.0 months). Significant pulmonary hypertension (PH) was defined as sPAP >50 mm Hg at rest or mean PAP >25 mm Hg on right heart catheterization. By perioperative sPAP changes, patients were stratified as group I (pre-normotension to post-normotension), group II (pre-hypertension to post-normotension), or group III (pre-hypertension to post-hypertension). Primary outcomes were the recurrence of MR (defined as the regurgitation grade of moderate or greater) and the progression of MR (defined as any increase in the magnitude of regurgitation grade after surgery). Cox proportional hazard and Kaplan-Meier curve were performed.

RESULTS

There was no association between preoperative PH and the recurrent MR (adjusted hazard ratios [aHR]: 1.146 [95% CI: 0.453-2.899]) and progressive MR (aHR: 1.753 [95% CI: 0.807-3.804]), respectively. There were no significant differences among group I, group II, and group III in the recurrent MR but in the progressive MR. A dose dependency was identified for preoperative sPAP with recurrent MR (aHR: 1.050 [95% CI: 1.029-1.071]) and progressive MR risks (aHR: 1.037 [95% CI: 1.019-1.055]), respectively.

CONCLUSIONS

Preoperative higher sPAP is associated with worse outcomes, warranting heightened attention to the identification of perioperative sPAP.

Tricuspid Regurgitation: Right Ventricular Volume Versus Pressure Load

PURPOSE OF THE REVIEW

Tricuspid regurgitation is associated with increased mortality in proportion to right ventricular adaptation to increased volume loading and pulmonary artery pressure. We here review recent progress in the understanding of right ventricular adaptation to pre- and after-loading conditions for improved recommendations of tricuspid valve repair.

RECENT FINDINGS

Trans-catheter tricuspid valve repair has made the correction of tricuspid regurgitation more easily available, triggering a need of tighter indications. Several studies have shown the feasibility and relevance to the indications of tricuspid valve repair of imaging of right ventricular ejection fraction measured by magnetic resonance imaging or 3D-echocardiography, and the 2D-echocardiography of the tricuspid annular plane systolic excursion to systolic pulmonary artery pressure ratio combined with invasively determined mean pulmonary artery pressure and pulmonary vascular resistance. Improved definitions of right ventricular failure and pulmonary hypertension may be considered in future recommendations on the treatment of tricuspid regurgitation.

Current status and future of cardio-obstetrics-review

Cardio-obstetrics refers to an approach to maternal care that is based upon teamwork with specialists from maternal-foetal medicine, cardiology, anaesthesiology, neonatology, nursing, social work, and pharmacy that work together to achieve appropriate outcomes for the pregnant patient. The aim of this paper is to highlight and provide a narrative review on the currently published research on the current status and future of cardio-obstetrics. A short review on the hemodynamic physiology in pregnancy has also been described in this paper. The authors have discussed the major risk factors associated with exacerbation of pregnancy and the possible remedies that are currently available in this paper in accordance to the updated research. The cardio-obstetrics team provides advice about healthy pregnancy planning before conception. Proper cardio-obstetric care is associated with better outcomes in women with a high cardiovascular risk with decreased adverse maternal and foetal outcomes. Such care should be given to underserved and marginalized communities with great care as they have largely lacked such care in the past. The authors conclude the paper by recommendations to advance this newly emerging field by way of further scientific research and public awareness. This review can serve helpful to any physician working in the healthcare as well as the public that are interested in awareness about the multidisciplinary needs of pregnant women with cardiovascular disease.

Endothelial cell senescence exacerbates pulmonary hypertension by inducing juxtacrine Notch signaling in smooth muscle cells

Pulmonary arterial hypertension (PAH) is a fatal disease characterized by a progressive increase in pulmonary artery pressure caused by pathological pulmonary artery remodeling. Here, we demonstrate that endothelial cell (EC) senescence plays a negative role in pulmonary hypertension via juxtacrine interaction with smooth muscle cells (SMCs). By using EC-specific progeroid mice, we discovered that EC progeria deteriorated vascular remodeling in the lungs, and exacerbated pulmonary hypertension in mice. Mechanistically, senescent ECs overexpressed Notch ligands, which resulted in increased Notch signaling and activated proliferation and migration capacities in neighboring SMCs. Pharmacological inhibition of Notch signaling reduced the effects of senescent ECs on SMCs functions in vitro, and improved the worsened pulmonary hypertension in EC-specific progeroid mice in vivo. Our findings show that EC senescence is a critical disease-modifying factor in PAH and that EC-mediated Notch signaling is a pharmacotherapeutic target for the treatment of PAH, particularly in the elderly.

Pulmonary arterial hypertension associated with congenital heart disease: An omics study

Pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) is a severely progressive condition with uncertain physiological course. Hence, it has become increasingly relevant to clarify the specific mechanisms of molecular modification, which is crucial to identify more treatment strategies. With the rapid development of high-throughput sequencing, omics technology gives access to massive experimental data and advanced techniques for systems biology, permitting comprehensive assessment of disease occurrence and progression. In recent years, significant progress has been made in the study of PAH-CHD and omics. To provide a comprehensive description and promote further in-depth investigation of PAH-CHD, this review attempts to summarize the latest developments in genomics, transcriptomics, epigenomics, proteomics, metabolomics, and multi-omics integration.

Differences in right ventricular function and response to targeted therapy between patients with IPAH and PAH-CHD

Background and aims: Pulmonary arterial hypertension (PAH) is a chronic pulmonary vascular disorder characterized by elevated pulmonary vascular resistance (PVR) and pulmonary arterial pressure (PAP). Right heart failure is a life-threatening complication of PAH and predicts a poor prognosis. PAH associated with congenital heart disease (PAH-CHD) and idiopathic PAH (IPAH) are two prevalent PAH subtypes in China. In this section, we set out to explore baseline right ventricular (RV) function and its response to targeted agents between IPAH and PAH-CHD. Methods and results: Consecutive patients diagnosed with IPAH or PAH-CHD by right heart catheterization (RHC) in the Second Xiangya Hospital from November 2011 to June 2020 were included. All patients received PAH-targeted therapy and the RV function was assessed by echocardiography at baseline and during follow-up. A total of 303 patients (age, 36.23 ± 13.10 years; women, 213 (70.3%); mean PAP [mPAP], 63.54 ± 16.12 mmHg; PVR, 14.74 ± 7.61 WU) with IPAH (n = 121) or PAH-CHD (n = 182) were included in this study. Compared with PAH-CHD, patients with IPAH had worse baseline RV function. As of the latest follow-up, forty-nine patients with IPAH and six patients with PAH-CHD died. Kaplan-Meier analyses showed better survival in PAH-CHD versus IPAH. After PAH-targeted therapy, patients with IPAH had less improvement in 6 MWD, World Health Organization functional class, and RV functional parameters compared with patients with PAH-CHD. Conclusion: Compared with patients with PAH-CHD, patients with IPAH had worse baseline RV function, unfavourable prognosis, and inadequate response to targeted treatment.

Right Heart Catheterization in Pediatric Pulmonary Arterial Hypertension: Insights and Outcome from a Large Tertiary Center

Aim: To define the clinical characteristics, hemodynamics, and adverse events for pediatric patients with pulmonary arterial hypertension (PAH) undergoing right heart catheterization (RHC). Methods: The large referral single center data of 591 diagnostic RHC procedures performed between 2005 and 2020 on pediatric PAH patients was retrospectively collected and analyzed. Results: A total of 591 RHC procedures performed on 469 patients with congenital heart disease (CHD)-PAH (median age 8.8 years, 7.9% New York Heart Association (NYHA) class > II, 1.5% with syncope) and 122 patients with idiopathic PAH (median age of 9.0 years, 27.0% NYHA class > II, 27.0% with syncope) were included. Of those, 373 (63.1%) procedures were performed under general anesthesia. Eighteen patients (18/591, 3.0%) suffered adverse events (mainly pulmonary hypertensive crisis, PHC, n = 17) during the RHC procedure, including 14 idiopathic pulmonary arterial hypertension (IPAH) patients and 4 CHD-PAH patients, and one IPAH patient died in hospital 63 hours after RHC. The risk of developing PHC was significantly increased in patients with IPAH (OR = 14.02, 95%CI: 4.49−43.85, p < 0.001), atrial blood gas pH < 7.35 (OR = 12.504, 95%CI: 3.545−44.102, p < 0.001) and RAP > 14 mmHg (OR = 10.636, 95%CI: 3.668−30.847, p < 0.001). Conclusions: RHC is generally a low-risk procedure in pediatric patients with PAH. However, PHC occur in approximately 3% of patients. Therefore, RHC should be performed in a large, experienced referral pediatric cardiology center, especially in pediatric patients with IPAH requiring general anesthesia.

NMR-Based Metabolomic Analysis of Plasma in Patients with Adult Congenital Heart Disease and Associated Pulmonary Arterial Hypertension: A Pilot Study

Patients with unrepaired congenital heart disease (CHD) are prone to pulmonary arterial hypertension (PAH). The ovine pulmonary arterial smooth muscle cells exposed to increased pulmonary blood flow (PBF) exhibited hyperproliferation and metabolic alterations, but the metabolic disorders of patients with CHD and associated PAH (PAH-CHD) have not yet been fully understood. Adult CHD patients were prospectively included and divided into the PAH-CHD group (n = 24) and CHD group (n = 38), while healthy adults were included as healthy control (HC) group (n = 29). Plasma from each subject was prepared for nuclear magnetic resonance (NMR) detection. ¹H-NMR spectra were acquired using 850 MHz NMR spectrometer. A total of 28 metabolites were identified from the NMR spectra and their relative concentrations were calculated and analyzed by multivariate and univariate statistical analyses and metabolic pathway analysis. Receiver operating characteristic (ROC) curve analysis and correlation analysis were performed to identify potential biomarkers and assess their roles in clinical assessment. Multivariate statistical analysis showed that the metabolic profile of PAH-CHD was altered relative to CHD or HC, while that of CHD was altered relative to HC. The identified characteristic metabolites were alanine, glucose, glycine, threonine and lactate, and the areas under the ROC curves (AUCs) were 0.769, 0.808, 0.711, 0.842 and 0.817, respectively. Multivariate ROC curve analysis showed AUCs ranging from 0.895 to 0.955 for the combination of these characteristic metabolites. The correlation analysis indicated that lactate and threonine were significantly correlated with mean pulmonary arterial pressure, pulmonary vascular resistance and N-terminal pro-B-type natriuretic peptide. The increased PBF could trigger global metabolic alterations in patients with CHD, which were more severe in patients with PAH-CHD. The characteristic metabolites have the potential to be biomarkers of PAH-CHD, which could be used for its noninvasive diagnosis, severity and prognosis assessment, thereby improving the management of PAH-CHD.

Evaluation of right ventricular myocardial strain in pulmonary arterial hypertension associated with atrial septal defect by cardiac magnetic resonance feature tracking

We aimed to research the role of right ventricular strain parameters (RVSP) quantified by cardiac magnetic resonance feature tracking (CMR-FT) in the early assessment of right ventricular (RV) function in patients with pulmonary arterial hypertension associated with atrial septal defect (PAH-ASD). From September 2017 to May 2021, we retrospectively enrolled 41 patients with PAH-ASD and 20 healthy controls. All subjects underwent CMR-FT, and right heart catheterization was conducted in patients with PAH-ASD. The relationship between RVSP and RV functional parameters was subjected to correlation analysis, and intragroup correlation coefficient (ICC) and Bland-Altman plots were used to assess the consistency. The subjects were divided into three groups: Group A (controls; n = 20), Group B (PAH-ASD, RVEF ≥ 45%; n = 14), and Group C (PAH-ASD, RVEF < 45%; n = 27). Compared with healthy controls, the RV global longitudinal strain (GLS) in Group B was significantly decreased (- 19.68 ± 2.72% vs. - 25.21 ± 3.6%, P < 0.05). In RVEF-preserved PAH-ASD patients (Group B), compared with patients with GLS ≤ - 20%, patients with GLS > - 20% also had significantly elevated right ventricular end-diastolic pressure (RVEDP) [8 (6.5-8.25) mmHg vs. 4.5 ± 1.64 mmHg, P < 0.05]. RV GLS had a moderate to strong correlation with RVEF, RVESVi, RVEDVi, RVEDP, and NT-proBNP (P < 0.05). ICC and Bland-Altman plots showed good intragroup and intergroup consistency in radial, circumferential and longitudinal strains of RV. In conclusion, it is feasible to quantify RV strain in patients with PAH-ASD by CMR-FT, and GLS is valuable for the early assessment of RV dysfunction in patients with PAH-ASD.

Apolipoprotein A1 is associated with pulmonary vascular resistance and adverse clinical outcomes in patients with pulmonary hypertension secondary to heart failure

Pulmonary hypertension secondary to heart failure (HF-PH) combined with pulmonary vascular remodeling has a high mortality rate. Apolipoprotein A1 (ApoA1) has been shown to adversely affect outcomes in patients with HF. A prospective follow-up study was performed on 239 consecutive patients with HF-PH who underwent right heart catheterization. Proteomics technology was used to analyze different proteins in plasma between post- and precapillary pulmonary hypertension (CpcPH) and isolated postcapillary pulmonary hypertension (IpcPH) filtered by propensity score matching. Ultimately, 175 patients were enrolled and followed for an average of 4.4 years. Lipoprotein components in plasma were measured, and the following clinical events were tracked. Proteomics data showed that lipid metabolism and inflammation were different between CpcPH and IpcPH. ApoA1 levels in HF-PH patients with CpcPH were lower than those in HF-PH patients with IpcPH. The patients with lower ApoA1 levels (≤1.025 g/L) were in a higher New York Heart Association class and had high levels of NT-proBNP, mean pulmonary artery pressure, PVR, and diastolic pressure gradient. Besides, HF-PH patients with lower ApoA1 levels had a 2.836-fold higher relative risk of comorbid CpcPH compared with patients with higher ApoA1 levels. Moreover, patients with lower ApoA1 levels had a lower survival rate after adjusting for CpcPH. In conclusion, ApoA1 levels were negatively correlated with PVR levels. Lower ApoA1 levels were an independent risk factor for pulmonary vascular remodeling in HF-PH patients. The survival of HF-PH patients with lower ApoA1 levels was reduced.

Maresin 1 intervention Reverses Experimental Pulmonary Arterial Hypertension in mice

BACKGROUND AND PURPOSE

Pulmonary arterial hypertension (PAH) is a pulmonary vasculature obstructive disease that leads to right heart failure and death. Maresin 1 is an endogenous lipid mediator known to promote inflammation resolution. However, the effect of Maresin 1 on PAH remains unclear.

EXPERIMENTAL APPROACH

The serum Maresin 1 concentration was assessed using UPLC. A mouse model of PAH was established by combining the Sugen 5416 injection and hypoxia exposure (SuHx). After treatment with Maresin 1, the right ventricular systolic pressure (RVSP) and right ventricular function were measured by hemodynamic measurement and echocardiography, respectively. Vascular remodeling was evaluated by histological staining. Confocal and western blot were used to test related protein expression. In vitro, cell migration, proliferation and apoptosis assays were performed in primary rat pulmonary artery smooth muscle cells (PASMCs). Western blotting and siRNA transfection were used to clarify the mechanism of Maresin 1.

KEY RESULTS

Endogenous serum Maresin 1 was decreased in PAH patients and mice. Maresin 1 treatment decreased RVSP and attenuated the right ventricular dysfunction (RVD) in murine PAH model. Maresin 1 reversed abnormal changes in pulmonary vascular remodeling, attenuating endothelial to mesenchymal transformation (EndoMT) and enhancing apoptosis of α-SMA positive cells. Furthermore, Maresin 1 inhibited PASMC proliferation and promoted apoptosis by inhibiting STAT, AKT, ERK and FoxO1 phosphorylation via LGR6.

CONCLUSION AND IMPLICATIONS

Maresin 1 improved abnormal pulmonary vascular remodeling and right ventricular dysfunction in PAH mice, targeting aberrant PASMC proliferation. This suggests Maresin 1 may have a potent therapeutic effect in vascular disease.

Accelerated Cardiac Aging in Patients With Congenital Heart Disease

An increasing number of patients with congenital heart disease (CHD) survive into adulthood but develop long-term complications including heart failure (HF). Cellular senescence, classically defined as stable cell cycle arrest, is implicated in biological processes such as embryogenesis, wound healing, and aging. Senescent cells have a complex senescence-associated secretory phenotype (SASP), involving a range of pro-inflammatory factors with important paracrine and autocrine effects on cell and tissue biology. While senescence has been mainly considered as a cause of diseases in the adulthood, it may be also implicated in some of the poor outcomes seen in patients with complex CHD. We propose that patients with CHD suffer from multiple repeated stress from an early stage of the life, which wear out homeostatic mechanisms and cause premature cardiac aging, with this term referring to the time-related irreversible deterioration of the organ physiological functions and integrity. In this review article, we gathered evidence from the literature indicating that growing up with CHD leads to abnormal inflammatory response, loss of proteostasis, and precocious age in cardiac cells. Novel research on this topic may inspire new therapies preventing HF in adult CHD patients.

Effect of postoperative administration of inhaled nitric oxide combined with high-frequency oscillatory ventilation in infants with acute hypoxemic respiratory failure and pulmonary hypertension after congenital heart surgery: A retrospective cohort study

OBJECTIVE

To evaluate the effect of inhaled nitric oxide (iNO) combined with high-frequency oscillatory ventilation (HFOV) in the treatment of infants with acute hypoxemic respiratory failure (AHRF) and pulmonary hypertension (PH) after congenital heart surgery.

METHODS

A retrospective study was conducted on 63 infants with AHRF and PH after congenital heart surgery in our cardiac intensive care unit (CICU) from January 2020 to March 2021. A total of 24 infants in the A group were treated with HFOV combined with iNO, and 39 infants in the B group were treated with HFOV. Relevant clinical data were collected.

RESULTS

Comparing the two groups, the improvement of the oxygenation index, PaO₂ and PaO₂ /FiO₂ was more obvious for patients in the A group than for those in the B group after intervention (p < .05). Reexamination on the third day after the initiation of HFOV treatment indicated that the systolic pulmonary artery pressure in the A group was significantly lower than that in the B group (p < .05). In addition, the duration of mechanical ventilation and the length of CICU stay in the A group were shorter than those in the B group (p < .05). However, complications between the two groups were not statistically significant. No important adverse effects arose.

CONCLUSIONS

For infants with AHRF and PH after congenital heart surgery, iNO combined with HFOV is superior to HFOV alone to improve oxygenation, decrease pulmonary pressure, and shorten the duration of mechanical ventilation and the length of CICU stay, with no adverse effects.

Clinical application of pulmonary vascular resistance in patients with pulmonary arterial hypertension

Pulmonary arterial hypertension is a type of malignant pulmonary vascular disease, which is mainly caused by the increase of pulmonary vascular resistance due to the pathological changes of the pulmonary arteriole itself, which eventually leads to right heart failure and death. As one of the diagnostic indicators of hemodynamics, pulmonary vascular resistance plays an irreplaceable role in the pathophysiology, diagnosis and treatment of pulmonary arterial hypertension. It provides more references for the evaluation of pulmonary arterial hypertension patients. This article summarizes the clinical application of pulmonary vascular resistance in patients with pulmonary arterial hypertension.

Computational simulation-derived hemodynamic and biomechanical properties of the pulmonary arterial tree early in the course of ventricular septal defects

Untreated ventricular septal defects (VSDs) can lead to pulmonary arterial hypertension (PAH) characterized by elevated pulmonary artery (PA) pressure and vascular remodeling, known as PAH associated with congenital heart disease (PAH-CHD). Though previous studies have investigated hemodynamic effects on vascular mechanobiology in late-stage PAH, hemodynamics leading to PAH-CHD initiation have not been fully quantified. We hypothesize that abnormal hemodynamics from left-to-right shunting in early stage VSDs affects PA biomechanical properties leading to PAH initiation. To model PA hemodynamics in healthy, small, moderate, and large VSD conditions prior to the onset of vascular remodeling, computational fluid dynamics simulations were performed using a 3D finite element model of a healthy 1-year-old's proximal PAs and a body-surface-area-scaled 0D distal PA tree. VSD conditions were modeled with increased pulmonary blood flow to represent degrees of left-to-right shunting. In the proximal PAs, pressure, flow, strain, and wall shear stress (WSS) increased with increasing VSD size; oscillatory shear index decreased with increasing VSD size in the larger PA vessels. WSS was higher in smaller diameter vessels and increased with VSD size, with the large VSD condition exhibiting WSS >100 dyn/cm[Formula: see text], well above values typically used to study dysfunctional mechanotransduction pathways in PAH. This study is the first to estimate hemodynamic and biomechanical metrics in the entire pediatric PA tree with VSD severity at the stage leading to PAH initiation and has implications for future studies assessing effects of abnormal mechanical stimuli on endothelial cells and vascular wall mechanics that occur during PAH-CHD initiation and progression.

Sodium-Glucose Cotransporter-2 Inhibitors in Vascular Biology: Cellular and Molecular Mechanisms

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are new antidiabetic drugs that reduce hyperglycemia by inhibiting the glucose reabsorption in renal proximal tubules. Clinical studies have shown that SGLT2 inhibitors not only improve glycemic control but also reduce major adverse cardiovascular events (MACE, cardiovascular and total mortality, fatal or nonfatal myocardial infarction or stroke) and hospitalization for heart failure (HF), and improve outcome in chronic kidney disease. These cardiovascular and renal benefits have now been confirmed in both diabetes and non-diabetes patients. The precise mechanism(s) responsible for the protective effects are under intensive investigation. This review examines current evidence on the cardiovascular benefits of SGLT2 inhibitors, with a special emphasis on the vascular actions and their potential mechanisms.

Sildenafil's Early, Late Impact on Ventricular Septal Repair: Older Children Using the Double Patch

BACKGROUND

Delayed diagnosis in children with a ventricular septal defect (VSD) is common in developing countries. Consequently, they present with elevated pulmonary vascular resistance (PVR) and pulmonary arterial hypertension (PAH). We introduced the double-flap valve VSD patch closure technique (DFV) in 1996 to reduce early post- operative risk. Long-term results are presented herein.

METHODS

This is a retrospective single-institution study on DFV patients performed between 5/1996 and 7/2015. Beginning in 2005 all candidates for DFV received sildenafil pre-and post-operatively. Pre-operative catheterization data, operative, post-operative, hospital and follow-up data were analyzed.

RESULTS

Forty patients received the DFV surgery. Patient demographics were comparable between sildenafil and non-sildenafil groups. Lost to follow up 1/39 (2.6%). Early mortality: 1/40 (2.5%), late mortality: 1/38 (2.6%). Sildenafil improved pre-op saturation, improved pre-operative hemodynamics as well as shortened prost-operative ventilation time. In both groups abnormal hemodynamic parameters improved with 100% oxygen challenge. The median age at late follow-up was 26.3 years (20.9; 29.9[25%; 75% Intra-quartile range]) and the median time since operation was 19.2 years (11.4; 22.7). Current discharge survival was 97.3%. Patients with severe PAH in late follow-up was 18%. Multi-variate analysis revealed only baseline PVR/SVR ≥ 0.8 as a significant predictor of late severe PAH.

CONCLUSIONS

Our long-term follow-up demonstrates that 60% of the patients will achieve normal or near normal PA pressures. Furthermore, we have demonstrated that sildenafil improves. pre-operative hemodynamics and post-operate management. Children with VSD, elevated PVR and PAH should not be denied operation.

Cellular senescence impairs the reversibility of pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) in congenital cardiac shunts can be reversed by hemodynamic unloading (HU) through shunt closure. However, this reversibility potential is lost beyond a certain point in time. The reason why PAH becomes irreversible is unknown. In this study, we used MCT+shunt-induced PAH in rats to identify a dichotomous reversibility response to HU, similar to the human situation. We compared vascular profiles of reversible and irreversible PAH using RNA sequencing. Cumulatively, we report that loss of reversibility is associated with a switch from a proliferative to a senescent vascular phenotype and confirmed markers of senescence in human PAH-CHD tissue. In vitro, we showed that human pulmonary endothelial cells of patients with PAH are more vulnerable to senescence than controls in response to shear stress and confirmed that the senolytic ABT263 induces apoptosis in senescent, but not in normal, endothelial cells. To support the concept that vascular cell senescence is causal to the irreversible nature of end-stage PAH, we targeted senescence using ABT263 and induced reversal of the hemodynamic and structural changes associated with severe PAH refractory to HU. The factors that drive the transition from a reversible to irreversible pulmonary vascular phenotype could also explain the irreversible nature of other PAH etiologies and provide new leads for pharmacological reversal of end-stage PAH.

Content validity of the nursing diagnostic Breathing Pattern, Ineffective, in children with congenital heart defects

OBJECTIVE

To estimate the content validity of the nursing diagnostic Breathing Pattern, Ineffective, in children with congenital heart defects.

METHOD

Methodological study in two stages: 1) integrative literature review; 2) content validation, with 23 nurses. An instrument with 10 related factors and 21 defining characteristics for data collection was used. The analysis by the evaluators was carried out using the relevance criteria. The Content Validity Index was used. Valid results were those above 0.9 with a Wilcoxon test above 0.05.

RESULTS

The final proposal incorporates nine from the ten causal factors. From them, five do not belong in the NANDA-I list. Regarding the defining characteristics, they were all considered to be relevant, and five are not among the list of signs and symptoms of the NANDA-I taxonomy.

CONCLUSION

The findings of this study include specific elements of the pediatric population with congenital heart defect which are not present in the structure of the diagnostic being studied.

Sera and lungs metabonomics reveals key metabolites of resveratrol protecting against PAH in rats

Pulmonary arterial hypertension (PAH) is a type of high morbidity and mortality disease. Currently, the intrinsic metabolic alteration and potential mechanism of PAH are still not fully uncovered. Previously, we have found that polyphenol resveratrol (Rev) reversed the remodeling of the pulmonary vasculature and decreased the number of mitochondria in pulmonary arterial smooth muscle cells (PASMCs) (Lei Yu et al. (2017)). However, potential effects of Rev on the changed metabolic molecules derived from lung tissue and serum have no fully elucidated. Thus, we conducted a systematic elaboration through the metabonomics method. Various of metabolites in different pathways including amino acid metabolism, tricarboxylic acid cycle (TCA), acetylcholine metabolism, fatty acid metabolism and biosynthesis in male Wistar rats' sera and lung tissues were explored in three groups (normal group, PAH group, PAH and Rev treatment group). We found that leucine and isoleucine degradation, valine, leucine and isoleucine biosynthesis, tryptophan metabolism and aminoacyl-tRNA biosynthesis were involved in the development of PAH. Hydroxyphenyllactic, isopalmitic acid and cytosine might be significant key metabolites. Further work in this area may inform personalized treatment approaches in clinical practice of PAH through elucidating pathophysiology mechanisms of experimental verification.

Echocardiography for the Assessment of Pulmonary Hypertension and Congenital Heart Disease in the Young

While invasive assessment of hemodynamics and testing of acute vasoreactivity in the catheterization laboratory is the gold standard for diagnosing pulmonary hypertension (PH) and pulmonary vascular disease (PVD) in children, transthoracic echocardiography (TTE) serves as the initial diagnostic tool. International guidelines suggest several key echocardiographic variables and indices for the screening studies when PH is suspected. However, due to the complex anatomy and special physiological considerations, these may not apply to patients with congenital heart disease (CHD). Misinterpretation of TTE variables can lead to delayed diagnosis and therapy, with fatal consequences, or–on the other hand-unnecessary invasive diagnostic procedures that have relevant risks, especially in the pediatric age group. We herein provide an overview of the echocardiographic workup of children and adolescents with PH with a special focus on children with CHD, such as ventricular/atrial septal defects, tetralogy of Fallot or univentricular physiology. In addition, we address the use of echocardiography as a tool to assess eligibility for exercise and sports, a major determinant of quality of life and outcome in patients with PH associated with CHD.

Animal models of right heart failure

Right heart failure may be the ultimate cause of death in patients with acute or chronic pulmonary hypertension (PH). As PH is often secondary to other cardiovascular diseases, the treatment goal is to target the underlying disease. We do however know, that right heart failure is an independent risk factor, and therefore, treatments that improve right heart function may improve morbidity and mortality in patients with PH. There are no therapies that directly target and support the failing right heart and translation from therapies that improve left heart failure have been unsuccessful, with the exception of mineralocorticoid receptor antagonists. To understand the underlying pathophysiology of right heart failure and to aid in the development of new treatments we need solid animal models that mimic the pathophysiology of human disease. There are several available animal models of acute and chronic PH. They range from flow induced to pressure overload induced right heart failure and have been introduced in both small and large animals. When initiating new pre-clinical or basic research studies it is key to choose the right animal model to ensure successful translation to the clinical setting. Selecting the right animal model for the right study is hence important, but may be difficult due to the plethora of different models and local availability. In this review we provide an overview of the available animal models of acute and chronic right heart failure and discuss the strengths and limitations of the different models.

Expression of serum miR-27b and miR-451 in patients with congenital heart disease associated pulmonary artery hypertension and risk factor analysis

This study investigated expression of serum miR-27b and miR-451 in patients with congenital heart disease associated pulmonary arterial hypertension (CHD-PAH), and analyzed the risk factors of CHD-PAH. A total of 114 patients with CHD admitted to the First Affiliated Hospital of the University of South China were recruited and allocated into a study group (61 patients with PAH) and a control group (53 patients without PAH). Reverse transcription-polymerase chain reaction (RT-PCR) was employed for the qualification of serum miR-27b and miR-451, and an automatic biochemical analyzer was used for the measurement of biochemical indexes in peripheral blood, and enzyme-linked immunosorbent assay (ELISA) for the detection of serum brain natriuretic peptide (BNP) and asymmetric dimethylarginine (ADMA). The patients with CHD-PAH showed higher serum miR-27b, BNP and ADMA but lower miR-451 than the controls. Serum miR-27b was positively correlated with mean pulmonary artery pressure (mPAP), BNP and ADMA, whereas serum miR-451 was negatively correlated with them. The combined detection of miR-27b and miR-451 was more valuable than a single detection in the diagnosis of CHD-PAH. Logistic regression analysis showed that ADMA, miR-27b, miR-451 and ventricular septal defect (VSD) were independent risk factors for CHD-PAH. In conclusion, miR-27b is highly expressed and miR-451 and the expression is low in patients with CHD-PAH. miR-27b and miR-451 are significantly correlated with BNP, ADMA, and the severity of the disease. The combination of miR-27b and miR-451 has high diagnostic value and can be used as a biomarker for the diagnosis and assessment of CHD-PAH. CHD-PAH is common in children with CHD, which poses a serious threat to the life and safety. At present, there are no effective methods for its early diagnosis and treatment. MicroRNAs (miRNAs, miRs) have been found to be closely related to the pathogenesis of CHD-PAH. In this study, miR-27b and miR-451 with differential expression in CHD-PAH were evaluated, and it was found that they were of great significance in the diagnosis and assessment of CHD-PAH.

The Effect of Perioperative Administration of Treprostinil in Infants with Non-restrictive Ventricular Septal Defect and Severe Pulmonary Arterial Hypertension

This study investigated the efficacy and safety of intravenous treprostinil during the perioperative period in infants with non-restrictive ventricular septal defect (VSD) and severe pulmonary arterial hypertension (PAH) undergoing surgical VSD repair. This was a retrospective study. There were 79 infants with non-restrictive VSD and severe PAH receiving surgical treatment from January to December 2019 in our cardiac center. The patients were divided into the treprostinil group and control group according to whether intravenous treprostinil was used during the perioperative period. There were no significant differences in the preoperative characteristics, including age, sex, weight, ventricular size, or preoperative pulmonary artery pressure, between the two groups. Although the pulmonary artery pressure in both groups was significantly lower postoperatively than preoperatively, the postoperative pulmonary artery systolic pressure was significantly lower in group T than in group C. The postoperative mechanical ventilation time, ICU stay, and hospital stay in group T were shorter than those in group C. Treprostinil can be used effectively and safely to reduce the perioperative pulmonary artery pressure in infants with non-restrictive VSD and severe PAH undergoing surgical VSD repair.

High plasma adiponectin is associated with increased pulmonary blood flow and reduced right ventricular function in patients with pulmonary hypertension

BACKGROUND

Adiponectin is a biomarker closely related to heart failure. However, its role in pulmonary hypertension remains unclear. In this study, we investigated the association between adiponectin and hemodynamic abnormalities, right ventricular function in patients with congenital heart disease associated pulmonary hypertension (CHD-PH).

METHODS

Patients with CHD-PH were enrolled in this cross-sectional study. Linear regression analysis was performed to assess the association between adiponectin, N-terminal pro-Brain Natriuretic Peptide (NT-proBNP) and different clinical parameters. Results were depicted as beta-estimates(ß) with 95%-confidence intervals (95% CI). In addition, mediation and receiver operating characteristic curve analyses were used to analyze the relationships among adiponectin, NT-proBNP and right ventricular function.

RESULTS

A total of 86 CHD-PH patients were included. The overall mean adiponectin concentration was 7.9 ± 5.8 μg/ml. Log adiponectin was positively correlated with pulmonary circulation index (ß = 2.2, 95% CI 0.5, 4.0), log NT-proBNP (ß = 0.22, 95% CI 0.04, 0.41) and inversely with the tricuspid annular plane systolic excursion (TAPSE, ß = -4.7, 95% CI -8.6, - 0.8). The mediation analysis revealed the association between NT-proBNP and TAPSE was fully mediated by adiponectin (total effect c = - 5.4, 95% CI -9.4, - 1.5, p = 0.013; direct effect c' = - 3.7, 95% CI -7.5, 0.1, p = 0.067). Additionally, the efficiency of adiponectin for detecting right ventricular dysfunction was not inferior to NT-proBNP (AUC = 0.84, 95% CI 0.67-1.00 vs AUC = 0.74, 95% CI 0.51-0.97, p = 0.23).

CONCLUSIONS

Adiponectin is closely correlated with pulmonary blood flow and right ventricular function and may be a valuable biomarker for disease assessment in patients with pulmonary hypertension.

Remodeling Matrix Synthesis in a Rat Model of Aortocaval Fistula and the Cyclic Stretch: Impaction in Pulmonary Arterial Hypertension-Congenital Heart Disease

Pulmonary arterial hypertension-congenital heart disease (PAH-CHD) is characterized by systemic to pulmonary arterial shunts and sensitively responds to volume overload and stretch of the vascular wall leading to pulmonary vascular remodeling. We hypothesized that the responses of pulmonary artery smooth muscle cells (PASMCs) to mechanical stress-associated volume overload may promote vascular remodeling in PAH-CHD. Here, we show that significantly increased collagen was in the PA adventitial layer by trichrome staining in PAH-CHD patients and an aortocaval fistula (ACF) rat model in which chronic vascular volume overload induced-PAH. We assessed the gene expression profiles of SMC markers, extracellular matrix, and collagen in isolated SMCs from pulmonary and thoracic vessels with cyclic stretch-triggered responses by real-time PCR analysis. The data corresponded to collagen deposition, which modulated pulmonary vascular remodeling in clinical and experimental PAH-ACF cases as well as in cyclic stretch-triggered SMCs in an in vitro model. We observe that collagen I A2 (COLIA2) is expressed in the control rat, but collagen I A1 (COLIA1) and Notchs remarkably increase in the lungs of ACF rats. Interestingly, closing the left-to-right shunt that leads to a reduced blood volume in the PA system of ACF rats (ACFRs) decreased the expression of COLIA1 and increased that of collagen I A2(COLIA2). This study contributes to the stretch-induced responses of SMCs and provides important future directions for therapies aimed at preventing abnormal matrix protein synthesis in volume overload-induced pulmonary hypertension (PH).

Residual Pulmonary Hypertension more than 20 Years after Repair of Shunt Lesions

Background and Objectives: After successful surgical repair of a congenital shunt lesion, pulmonary hypertension (PH) often disappears. However, PH can persist long-term after the closure. This study aimed to assess the prevalence of PH long-term after surgical repair of congenital heart disease (CHD), and to evaluate the outcomes and preoperative factors related to residual PH. Materials and Methods: In this retrospective cohort study, we reviewed patients who underwent right heart catheterisation in Vilnius University Hospital Santaros Klinikos during the period of 1985–2007. Among 4118 right heart catheterisations performed, 160 patients underwent congenital systemic-to-pulmonary shunt repair at a young age (<18 years) and had pre-operative PH. Half of the patients were foreigners whose follow-up data were unavailable. Eventually, 88 patients with available follow-up data were included in this study. Results: The median age at diagnosis of CHD with PH was 0.8 (0.6–3.0) and 1.1 (0.6–3.9) years at surgery (50% females). Residual PH was assessed 9.5 years after surgery and observed in 30.7% (n = 27) of the patients. It was associated with having more than one shunt (44.4% (n = 12), p = 0.016) and higher median pulmonary vascular resistance (3.4 (2.5–6.5) vs. 2.2 (1.0–3.7), p = 0.035) at baseline. After a median follow-up of 21 (15–24) years, 9.1% of the patients were deceased. Kaplan–Meier survival analysis revealed significantly higher mortality in the residual PH group (p = 0.035). Conclusions: Residual PH affects a significant proportion of patients after surgical repair of a shunt lesion and is associated with worse long-term outcome.

Mechanical forces alter endothelin-1 signaling: comparative ovine models of congenital heart disease

The risk and progression of pulmonary vascular disease in patients with congenital heart disease is dependent on the hemodynamics associated with different lesions. However, the underlying mechanisms are not understood. Endothelin-1 is a potent vasoconstrictor that plays a key role in the pathology of pulmonary vascular disease. We utilized two ovine models of congenital heart disease: (1) fetal aortopulmonary graft placement (shunt), resulting in increased flow and pressure; and (2) fetal ligation of the left pulmonary artery resulting in increased flow and normal pressure to the right lung, to investigate the hypothesis that high pressure and flow, but not flow alone, upregulates endothelin-1 signaling. Lung tissue and pulmonary arterial endothelial cells were harvested from control, shunt, and the right lung of left pulmonary artery lambs at 3–7 weeks of age. We found that lung preproendothelin-1 mRNA and protein expression were increased in shunt lambs compared to controls. Preproendothelin-1 mRNA expression was modestly increased, and protein was unchanged in left pulmonary artery lambs. These changes resulted in increased lung endothelin-1 levels in shunt lambs, while left pulmonary artery levels were similar to controls. Pulmonary arterial endothelial cells exposed to increased shear stress decreased endothelin-1 levels by five-fold, while cyclic stretch increased levels by 1.5-fold. These data suggest that pressure or an additive effect of pressure and flow, rather than increased flow alone, is the principal driver of increased endothelin signaling in congenital heart disease. Defining the molecular drivers of the pathobiology of pulmonary vascular disease due to differing mechanical forces will allow for a more targeted therapeutic approach.

Image diagnosis: Eisenmenger's syndrome in patients with simple congenital heart disease

BACKGROUND

Early identification of congenital heart disease (CHD) allows detection of the pulmonary arteriopathy in an early stage, and timely shunt closure can permanently reverse pulmonary arterial hypertension (PAH). However, surgical correction is not recommended in patients with irreversible PAH. Herein we report our experience about Eisenmenger's syndrome in simple CHD.

CASE PRESENTATION

From January 2017 to November 2018, a total of 8 CHD patients (3 ventricular septal defects (VSD), 2 atrial septal defects (ASD), and 3 patent ductus arteriosus (PDA), median age, 15.5 years [range, 3-18 years]) with PAH were detected by chest X-ray, electrocardiogram, transthoracic echocardiography (TTE), computed tomographic angiography (CTA) and cardiac catheterization. The median defect diameter, pulmonary artery pressure (PAP), pulmonary vascular resistance (PVR) were 16.5 mm (range, 3-30 mm), 75 mmHg (range, 60-86 mmHg), and 16 Woods units (range, 12-19 Woods units), respectively. Here, we report the representative cases of three types of simple CHD with irreversible PAH. The surgical correction was not performed in all patients who had fixed PAH and were referred to medical treatment.

CONCLUSIONS

PAH in CHD can be reversed by early shunt closure, but this potential is lost beyond a certain point of no return. This article highlights the essence of enhancing the level of healthcare and services in Chinese rural areas. Failure to accurately and timely assess PAH will delay effective treatment past optimal treatment time, and even lead to death.

Effects of treprostinil on pulmonary arterial hypertension during surgery for congenital heart disease complicated with severe pulmonary arterial hypertension

BACKGROUND

The aim of this study is to evaluate the effects of treprostinil injection on the control of pulmonary blood pressure in children with congenital heart disease (CHD) complicated by severe pulmonary arterial hypertension (PAH).

METHODS

Eighty children with CHD complicated by severe pulmonary arterial hypertension admitted to our hospital from January 2015 to June 2018 were selected and randomly divided into a control group (N.=40) and a treatment group (N.=40). Based on standard treatment, the treatment group was intravenously infused with 8-12 ng/kg·min treprostinil, while the control group received the same dose of normal saline. Hemodynamic parameters such as BP, AP, P and SpO<inf>2</inf>% were monitored before anesthesia induction (T0), before cardiopulmonary bypass (T1), 1 h after cardiopulmonary bypass (T2) and at the end of cardiopulmonary bypass (T3). Pulmonary arterial pressure parameters (PASP, PADP and PAMP) were measured at T1, T2 and T3 by transesophageal echocardiography.

RESULTS

For the treatment group, the HR values at T2 and T3 were lower than that at T0 (P<0.05). For the control group, HR at T3 was lower than that at T0 (P<0.05). HR at T3 of the treatment group was lower than that of the control group (P<0.05). SpO<inf>2</inf> of the treatment group was higher than that of the control group at T3 (P<0.05). At T2 and T3, PASP, PADP and PAMP of both groups were lower than those before surgery (P<0.05), and the values of the treatment group were lower than those of the control group (P<0.05).

CONCLUSIONS

Treprostinil can improve cardiac function and reduce pulmonary circulation resistance in PAH children.

Is There Value in Repeating Inhaled Nitric Oxide Vasoreactivity Tests in Patients with Pulmonary Arterial Hypertension?

BACKGROUND

In patients with pulmonary arterial hypertension (PAH), it remains unknown if the response to the acute pulmonary vasoreactivity test changes over time and determines prognosis.

METHODS

We included PAH patients who underwent two right heart catheterizations (RHC) with acute vasoreactivity challenge using inhaled nitric oxide (NO). The hemodynamic response was assessed by absolute or percentage change in mean pulmonary artery pressure (mPAP) or pulmonary vascular resistance (PVR).

RESULTS

We included 54 patients, age 51 ± 17 years, and 44 (82%) female. The median (IQR) time between the two RHC was 24.5 months (14.8-42 months). The percentage drop in mPAP was less pronounced in the second RHC (- 8.6 ± 8.1 versus - 12.3 ± 13.8 mmHg, p = 0.02). A total of 8 (14%) patients met criteria for a positive vasodilatory test during the first RHC but only 1 during the second. Patients with increased vasoreactivity at second RHC were more likely to receive (a) treatment with phosphodiesterase-5 inhibitors (PDE5-inh) at first RHC (56% versus 27%, p = 0.04) and (b) more PAH-specific medications by second RHC (2.3 ± 0.8 versus 1.8 ± 0.9, p = 0.03). Cox survival analysis showed that change in mPAP or PVR during vasodilatory challenge at or between the first and second RHC had no impact on survival.

CONCLUSIONS

Pulmonary vascular reactivity to inhaled NO might decrease over time; however, there is great variability among patients. The use of PDE5-inh at first RHC and number of PAH-specific treatments by the second RHC were associated with an improvement in pulmonary vasoreactivity over time.

Multicenter Preclinical Validation of BET Inhibition for the Treatment of Pulmonary Arterial Hypertension

Rationale: Pulmonary arterial hypertension (PAH) is a degenerative arteriopathy that leads to right ventricular (RV) failure. BRD4 (bromodomain-containing protein 4), a member of the BET (bromodomain and extra-terminal motif) family, has been identified as a critical epigenetic driver for cardiovascular diseases.Objectives: To explore the therapeutic potential in PAH of RVX208, a clinically available BET inhibitor.Methods: Microvascular endothelial cells, smooth muscle cells isolated from distal pulmonary arteries of patients with PAH, rats with Sugen5416 + hypoxia- or monocrotaline + shunt-induced PAH, and rats with RV pressure overload induced by pulmonary artery banding were treated with RVX208 in three independent laboratories.Measurements and Main Results: BRD4 is upregulated in the remodeled pulmonary vasculature of patients with PAH, where it regulates FoxM1 and PLK1, proteins implicated in the DNA damage response. RVX208 normalized the hyperproliferative, apoptosis-resistant, and inflammatory phenotype of microvascular endothelial cells and smooth muscle cells isolated from patients with PAH. Oral treatment with RVX208 reversed vascular remodeling and improved pulmonary hemodynamics in two independent trials in Sugen5416 + hypoxia-PAH and in monocrotaline + shunt-PAH. RVX208 could be combined safely with contemporary PAH standard of care. RVX208 treatment also supported the pressure-loaded RV in pulmonary artery banding rats.Conclusions: RVX208, a clinically available BET inhibitor, modulates proproliferative, prosurvival, and proinflammatory pathways, potentially through interactions with FoxM1 and PLK1. This reversed the PAH phenotype in isolated PAH microvascular endothelial cells and smooth muscle cells in vitro, and in diverse PAH rat models. RVX208 also supported the pressure-loaded RV in vivo. Together, these data support the establishment of a clinical trial with RVX208 in patients with PAH.