The practical management of fluid retention in adults with right heart failure due to pulmonary arterial hypertension

The effects of bolus isosorbide dinitrate on pulmonary hypertension with cardiopulmonary comorbidities

Lowering mean pulmonary arterial pressure (mPAP) without reducing cardiac output is essential in treating pulmonary hypertension (PH). Isosorbide dinitrate (ISDN) potentially achieves this in post-capillary PH but can decrease cardiac output and blood pressure (BP), especially in pre-capillary PH. However, post-capillary PH and pre-capillary PH can overlap, and their clear discrimination is difficult. The aim of the study was to examine to what extent bolus ISDN injection reduces mPAP and BP, and changes mixed venous oxygen saturation (SvO2), an indicator of cardiac output in PH with various cardiopulmonary comorbidities in the context of treatment modifications. We retrospectively examined the hemodynamic effects of bolus ISDN injection in patients with PH who underwent right heart catheterization and their subsequent treatment modification. Our sample comprised 13 PH patients. In seven with pre-capillary PH, ISDN significantly lowered mPAP from the median 34 (interquartile range 32-39) to 28 (28-30) mmHg and the mean BP (mBP) from 90 (79-92) to 72 (68-87) mmHg. In six with post-capillary PH, ISDN lowered mPAP from 40 (29-44) to 27 (23-31) mmHg and mBP from 91 (87-110) to 87 (82-104) mmHg. There was a significant decrease in SvO2 from 69.8% (64.9%-78.1%) to 63.9% (60.5%-71.5%) in pre-capillary PH, but not in post-capillary PH including combined post- and pre-capillary PH and some patients showed a large increase in SvO2. In all patients showing an SvO2 increase, diuretics or hemodialysis were up-titrated or continued. Bolus ISDN injection lowered mPAP. However, in pre-capillary PH, it caused a significant decrease in SvO2 and a notable reduction in blood pressure. In post-capillary PH, including combined post- and pre-capillary PH, it clarified whether systemic preload and afterload reduction increased or decreased SvO2 in each patient, which may aid in treatment modification.

Predictive Analysis of the Mortality Rate of Patients with Heart Failure Complicated by Acute Kidney Failure Based on the Fluid Balance: A Retrospective Study Using the MIMIC-IV Database

BACKGROUND

Heart failure (HF) is a global health issue, and its complication with acute kidney failure (AKF) increases the risk of mortality. This study aimed to investigate the predictive value of fluid balance for mortality in patients with HF complicated by AKF. A retrospective analysis was performed using the MIMIC-IV database to evaluate the relationship between fluid balance and mortality in patients with HF complicated by AKF.

MATERIAL AND METHODS

Adult patients with HF and AKF and who were listed in the MIMIC-IV database between 2008 and 2019 were included. The patients were divided into survival and non-survival groups. The primary outcome measure was fluid intake and output in the first three days in the intensive care unit (ICU). The main outcome being in-ICU mortality and the secondary outcome being 28‑day mortality after ICU admission. A multivariable Cox proportional hazards model was used to assess the relationship between fluid balance and the risk of death, after adjusting for potential confounding factors.

RESULTS

A total of 1433 eligible patients were included. The study found that compared to the death group, patients in the survival group maintained lower positive balance on day 1 (453.51 ml vs 1813.66 ml), negative balance on day 2 (-246.75 ml vs 646.00 ml), and negative balance on day 3 (-350.21 ml vs 312.92 ml). Additionally, fluid balance on the first day predicted ICU mortality rate (AUC 0.658, p<0.01), on the second day it predicted ICU mortality rate (AUC 0.654, p<0.01), and on the third day it also predicted ICU mortality rate (AUC 0.634, p<0.01).

CONCLUSION

Positive fluid balance in patients with HF and AKF is independently associated with higher in-hospital mortality. Monitoring and managing fluid balance may provide clinicians with an important tool to improve patient outcomes.

Management of Critically Ill Patients With Pulmonary Arterial Hypertension in Transport: A Narrative Review

Pulmonary arterial hypertension (PAH) is a unique disease process with a highly complex physiology. Patients with PAH are often on specialized medications that exert specific hemodynamic effects. Furthermore, when they become critically ill, the management strategy can be counterintuitive. Commonly accepted, evidence-based management for the general population, such as fluid boluses in the setting of sepsis, can be harmful to this patient cohort. Often, these patients require highly specialized care at tertiary and quaternary centers, which necessitates critical care transport. Therefore, it is important that critical care transport crews understand the distinctive pathophysiology and management of critically ill patients with PAH.

SGLT2 inhibitors as a potential therapeutic option for pulmonary hypertension: mechanisms and clinical perspectives

Pulmonary arterial hypertension (PAH), one subtype of pulmonary hypertension (PH), is a life-threatening condition characterized by pulmonary arterial remodeling, elevated pulmonary vascular resistance, and blood pressure in the pulmonary arteries, leading to right heart failure and increased mortality. The disease is marked by endothelial dysfunction, vasoconstriction, and vascular remodeling. The role of Sodium-Glucose Co-Transporter-2 (SGLT2) inhibitors, a class of medications originally developed for diabetes management, is increasingly being explored in the context of cardiovascular diseases, including PAH, due to their potential to modulate these pathophysiological processes. In this review, we systematically examine the burgeoning evidence from both basic and clinical studies that describe the effects of SGLT2 inhibitors on cardiovascular health, with a special emphasis on PAH. By delving into the complex interactions between these drugs and the potential pathobiology that underpins PH, this study seeks to uncover the mechanistic underpinnings that could justify the use of SGLT2 inhibitors as a novel therapeutic approach for PAH. We collate findings that illustrate how SGLT2 inhibitors may influence the normal function of pulmonary arteries, possibly alleviating the pathological hallmarks of PAH such as inflammation, oxidative stress, aberrant cellular proliferation, and so on. Our review thereby outlines a potential paradigm shift in PAH management, suggesting that these inhibitors could play a crucial role in modulating the disease's progression by targeting the potential dysfunctions that drive it. This comprehensive synthesis of existing research underscores the imperative need for further clinical trials to validate the efficacy of SGLT2 inhibitors in PAH and to integrate them into the therapeutic agents used against this challenging disease.

Pulmonary arterial hypertension: Navigating the pathways of progress in diagnosis, treatment, and patient care

Pulmonary arterial hypertension (PAH) is a form of precapillary pulmonary hypertension caused by a complex process of endothelial dysfunction and vascular remodeling. If left untreated, this progressive disease presents with symptoms of incapacitating fatigue causing marked loss of quality of life, eventually culminating in right ventricular failure and death. Patient management is complex and based on accurate diagnosis, risk stratification, and treatment initiation, with close monitoring of response and disease progression. Understanding the underlying pathophysiology has enabled the development of multiple drugs directed at different targets in the pathological chain. Vasodilator therapy has been the mainstay approach for the last few years, significantly improving quality of life, functional status, and survival. Recent advances in therapies targeting dysfunctional pathways beyond endothelial dysfunction may address the fundamental processes underlying the disease, raising the prospect of increasingly effective options for this high-risk group of patients with a historically poor prognosis.

The Bidirectional Relationship Between Cardiovascular Medications and Oral and Gut Microbiome Health: A Comprehensive Review

Cardiovascular diseases (CVDs) are a leading cause of widespread morbidity and mortality. It has been found that the gut and oral microbiomes differ in individuals with CVDs compared to healthy individuals. Patients with CVDs often require long-term pharmacological interventions. While these medications have been extensively studied for their cardiovascular benefits, emerging research indicates that they may also impact the diversity and composition of the oral and gut microbiomes. However, our understanding of how these factors influence the compositions of the oral and gut microbiomes in individuals remains limited. Studies have shown that statins and beta-blockers, in particular, cause gut and oral microbial dysbiosis, impacting the metabolism and absorption of these medications. These alterations can lead to variations in drug responses, highlighting the need for personalized treatment approaches. The microbiome's role in drug metabolism and the impact of CVD medications on the microbiome are crucial in understanding these variations. However, there are very few studies in this area, and not all medications have been studied, emphasizing the necessity for further research to conclusively establish cause-and-effect relationships and determine the clinical significance of these interactions. This review will provide evidence of how the oral and gut microbiomes in patients with cardiovascular diseases (CVDs) interact with specific drugs used in CVD treatment.

Pulmonary hypertension and chronic kidney disease: prevalence, pathophysiology and outcomes

Pulmonary hypertension (PH) is common in patients with chronic kidney disease (CKD) or kidney failure, with an estimated prevalence of up to 78% in those referred for right-heart catheterization. PH is independently associated with adverse outcomes in CKD, raising the possibility that early detection and appropriate management of PH might improve outcomes in at-risk patients. Among patients with PH, the prevalence of CKD stages 3 and 4 is estimated to be as high as 36%, and CKD is also independently associated with adverse outcomes. However, the complex, heterogenous pathophysiology and clinical profile of CKD-PH requires further characterization. CKD is often associated with elevated left ventricular filling pressure and volume overload, which presumably leads to pulmonary vascular stiffening and post-capillary PH. By contrast, a distinct subgroup of patients at high risk is characterized by elevated pulmonary vascular resistance and right ventricular dysfunction in the absence of pulmonary venous hypertension, which may represent a right-sided cardiorenal syndrome defined in principle by hypervolaemia, salt avidity, low cardiac output and normal left ventricular function. Current understanding of CKD-PH is limited, despite its potentially important ramifications for clinical decision making. In particular, whether PH should be considered when determining the suitability and timing of kidney replacement therapy or kidney transplantation is unclear. More research is urgently needed to address these knowledge gaps and improve the outcomes of patients with or at risk of CKD-PH.

Diagnosis and Management of Pulmonary Hypertension: New Insights

Over the last decades, significant progress has been achieved in the pulmonary hypertension (PH) field. Pathophysiology of PH has been studied, leading to the classification of PH patients into five groups, while the hemodynamic definition has been recently revised. A diagnostic algorithm has been established and awareness has been raised in order to minimize diagnosis delay. The pulmonary arterial hypertension (PAH) treatment strategy includes the established three pathways of endothelin, nitric oxide-phosphodiesterase inhibitor, and prostacyclin pathway, but new therapeutic options are now being tested. The aim of this review is to summarize the existing practice and to highlight the novelties in the field of PH.

Perioperative Right Ventricular Dysfunction and Abnormalities of the Tricuspid Valve Apparatus in Patients Undergoing Cardiac Surgery

Right ventricular (RV) dysfunction frequently occurs after cardiac surgery and is linked to adverse postoperative outcomes, including mortality, reintubation, stroke, and prolonged ICU stays. While various criteria using echocardiography and hemodynamic parameters have been proposed, a consensus remains elusive. Distinctive RV anatomical features include its thin wall, which presents a triangular shape in a lateral view and a crescent shape in a cross-sectional view. Principal causes of RV dysfunction after cardiac surgery encompass ischemic reperfusion injury, prolonged ischemic time, choice of cardioplegia and its administration, cardiopulmonary bypass weaning characteristics, and preoperative risk factors. Post-left ventricular assist device (LVAD) implantation RV dysfunction is common but often transient, with a favorable prognosis upon resolution. There is an ongoing debate regarding the benefits of concomitant surgical repair of the RV in the presence of regurgitation. According to the literature, the gold standard techniques for assessing RV function are cardiac magnetic resonance imaging and hemodynamic assessment using thermodilution. Echocardiography is widely favored for perioperative RV function evaluation due to its accessibility, reproducibility, non-invasiveness, and cost-effectiveness. Although other techniques exist for RV function assessment, they are less common in clinical practice. Clinical management strategies focus on early detection and include intravenous drugs (inotropes and vasodilators), inhalation drugs (pulmonary vasodilators), ventilator strategies, volume management, and mechanical support. Bridging research gaps in this field is crucial to improving clinical outcomes associated with RV dysfunction in the near future.

Pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a rare and progressive disease characterised by remodelling of the pulmonary arteries and progressive narrowing of the pulmonary vasculature. This leads to a progressive increase in pulmonary vascular resistance and pulmonary arterial pressure and, if left untreated, to right ventricular failure and death. A correct diagnosis requires a complete work-up including right heart catheterisation performed in a specialised centre. Although our knowledge of the epidemiology, pathology and pathophysiology of the disease, as well as the development of innovative therapies, has progressed in recent decades, PAH remains a serious clinical condition. Current treatments for the disease target the three specific pathways of endothelial dysfunction that characterise PAH: the endothelin, nitric oxide and prostacyclin pathways. The current treatment algorithm is based on the assessment of severity using a multiparametric risk stratification approach at the time of diagnosis (baseline) and at regular follow-up visits. It recommends the initiation of combination therapy in PAH patients without cardiopulmonary comorbidities. The choice of therapy (dual or triple) depends on the initial severity of the condition. The main treatment goal is to achieve low-risk status. Further escalation of treatment is required if low-risk status is not achieved at subsequent follow-up assessments. In the most severe patients, who are already on maximal medical therapy, lung transplantation may be indicated. Recent advances in understanding the pathophysiology of the disease have led to the development of promising emerging therapies targeting dysfunctional pathways beyond endothelial dysfunction, including the TGF-β and PDGF pathways.

Pharmacological management of connective tissue disease-associated pulmonary arterial hypertension

INTRODUCTION

Pulmonary arterial hypertension (PAH) is a severe, progressive pulmonary vasculopathy (Group 1 Pulmonary Hypertension (PH)) that complicates the course of many connective tissue diseases (CTD). Detailed testing is required to differentiate PAH from other types of PH caused by CTD such as left heart disease (Group 2 PH), pulmonary parenchymal disease (Group 3 PH), and chronic thromboembolic pulmonary hypertension (Group 4 PH). PAH is most frequently seen in systemic sclerosis but can also be seen with systemic lupus erythematosus, mixed CTD, and primary Sjogren's syndrome.

AREAS COVERED

This review discusses the epidemiology of CTD-associated PAH, outlines the complex diagnosis approach, and finishes with an in-depth discussion on the current treatment paradigm. Focus is placed on challenges faced in the treatment of CTD-associated PAH, (decreased efficacy and poorer tolerance of pharmacological therapies) and includes a discussion on the future investigational treatments.

EXPERT OPINION

Despite significant advances over the past decades with more aggressive treatment algorithms, CTD-associated PAH patients continue to have poorer survival compared to those with idiopathic PAH. This review highlights factors leading to disparate outcomes compared to other forms of PAH, and discusses on further improvements that may increase quality of life and survival for CTD-associated PAH patients.

Computer simulation of surgical interventions for the treatment of refractory pulmonary hypertension

This paper describes computer models of three interventions used for treating refractory pulmonary hypertension (RPH). These procedures create either an atrial septal defect, a ventricular septal defect or, in the case of a Potts shunt, a patent ductus arteriosus. The aim in all three cases is to generate a right-to-left shunt, allowing for either pressure or volume unloading of the right side of the heart in the setting of right ventricular failure, while maintaining cardiac output. These shunts are created, however, at the expense of introducing de-oxygenated blood into the systemic circulation, thereby lowering the systemic arterial oxygen saturation. The models developed in this paper are based on compartmental descriptions of human hemodynamics and oxygen transport. An important parameter included in our models is the cross-sectional area of the surgically created defect. Numerical simulations are performed to compare different interventions and various shunt sizes and to assess their impact on hemodynamic variables and oxygen saturations. We also create a model for exercise and use it to study exercise tolerance in simulated pre-intervention and post-intervention RPH patients.

Allgemeine Therapie der pulmonalarteriellen Hypertonie nach den neuen Leitlinien

In den neuen Leitlinien (LL) für pulmonalarterielle Hypertonie (PAH) sind die allgemeinen Maßnahmen ein integraler Bestandteil der Behandlung der Patienten. Auch die systemischen Auswirkungen der pulmonalen Hypertonie und Rechtsherzinsuffizienz sollten angemessen berücksichtigt und behandelt werden. Im folgenden Artikel werden die in den LL genannten Maßnahmen unter Berücksichtigung des bestehenden Empfehlungsgrads und der Evidenzen beschrieben. Leider sind die meisten Allgemeinmaßnahmen, wie die Gabe von Diuretika, Sauerstoff, psychosozialer Support und Impfungen, nicht oder unzureichend in randomisierten, kontrollierten Studien untersucht worden. So haben sie zwar einen hohen I-Empfehlungsgrad, aber einen niedrigen Evidenzgrad C. Nur bei dem spezialisierten körperlichen Training liegen bislang insgesamt 7 randomisierte, kontrollierte Studien und 5 Metaanalysen vor, die eine Verbesserung der Sauerstoffaufnahme, körperlichen Belastbarkeit, der Beschwerden (WHO-Funktionsklasse), Lebensqualität und Hämodynamik nachgewiesen haben (daher neu IA-Empfehlung). Auch weitere Maßnahmen wie die Antikoagulation, Eisensubstitution und andere werden im Folgenden besprochen.

Computational modelling of multi-temporal ventricular-vascular interactions during the progression of pulmonary arterial hypertension

A computational framework is developed to consider the concurrent growth and remodelling (G&R) processes occurring in the large pulmonary artery (PA) and right ventricle (RV), as well as ventricular-vascular interactions during the progression of pulmonary arterial hypertension (PAH). This computational framework couples the RV and the proximal PA in a closed-loop circulatory system that operates in a short timescale of a cardiac cycle, and evolves over a long timescale due to G&R processes in the PA and RV. The framework predicts changes in haemodynamics (e.g. 68.2% increase in mean PA pressure), RV geometry (e.g. 38% increase in RV end-diastolic volume) and PA tissue microstructure (e.g. 90% increase in collagen mass) that are consistent with clinical and experimental measurements of PAH. The framework also predicts that a reduction in RV contractility is associated with long-term RV chamber dilation, a common biomarker observed in the late-stage PAH. Sensitivity analyses on the G&R rate constants show that large PA stiffening (both short and long term) is affected by RV remodelling more than the reverse. This framework can serve as a foundation for the future development of a more predictive and comprehensive cardiovascular G&R model with realistic heart and vascular geometries.

Diagnosis and Management of Failed Surgical Tricuspid Valve Annuloplasty

PURPOSE OF THE REVIEW

Annular-based strategies for treating tricuspid valve (TV) regurgitation do not always have satisfactory long-term outcomes. Management of failed TV annuloplasty can be challenging and requires a dedicated heart team approach. This review explores the treatment options available for failed TV annuloplasty.

RECENT FINDINGS

Recent developments and novel percutaneous treatment options have emerged as promising alternatives for patients with failed TV annuloplasty. Leaflet-based interventions, valve-in-valve procedures, transcatheter tricuspid valves and new-generation trans-caval valves are all feasible options, which can assure good results whilst minimizing risks for the patient. Failure of tricuspid annuloplasty is not uncommon amongst patients treated with either a tricuspid ring or suture-based device. The complex anatomy, physiology and clinical risk profile should be carefully evaluated on an individual patient-by-patient basis in order to select the most appropriate clinical and percutaneous treatment strategy. Different transcatheter tricuspid valve repair or replacement techniques may provide an attractive alternative treatment option for managing this challenging patient cohort.

Perioperative Management of Pulmonary Hypertension. a Review

Pulmonary hypertension is a rare and progressive pathology defined by abnormally high pulmonary artery pressure mediated by a diverse range of aetiologies. It affects up to twenty-six individuals per one million patients currently living in the United Kingdom (UK), with a median life expectancy of 2.8 years in idiopathic pulmonary hypertension. The diagnosis of pulmonary hypertension is often delayed due to the presentation of non-specific symptoms, leading to a delay in referral to specialists services. The complexity of treatment necessitates a multidisciplinary approach, underpinned by a diverse disease aetiology from managing the underlying disease process to novel specialist treatments. This has led to the formation of dedicated specialist treatment centres within centralised UK cities. The article aimed to provide a concise overview of pulmonary hypertension's clinical perioperative management, including key definitions, epidemiology, pathophysiology, and risk stratification.