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Gerges C, Montani D, Humbert M, Lang IM. Haemodynamic phenotypes of pulmonary hypertension associated with left heart disease: a moving target. Eur Respir J 2024; 63:2302280. [PMID: 38359964 PMCID: PMC10938349 DOI: 10.1183/13993003.02280-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/05/2024] [Indexed: 02/17/2024]
Abstract
Shifting haemodynamic definitions impact prevalence of CpcPH in PH associated with left heart disease. Diastolic pressure gradient ≥7 mmHg and pulmonary vascular resistance >5 WU predict pulmonary vascular disease similarly well. https://bit.ly/3OEG5pw
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Affiliation(s)
- Christian Gerges
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - David Montani
- Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Le Kremlin-Bicêtre, France
| | - Irene M. Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
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2
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Schmidt KH, Bikou O, Blindt R, Bruch L, Felgendreher R, Hohenforst-Schmidt W, Holt S, Ladage D, Pfeuffer-Jovic E, Rieth A, Schmeisser A, Schnitzler K, Stadler S, Steringer-Mascherbauer R, Yogeswaran A, Kuebler WM. [Pulmonary hypertension associated with left heart disease (group 2)]. Pneumologie 2023; 77:926-936. [PMID: 37963482 DOI: 10.1055/a-2145-4792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Pulmonary hypertension associated with left heart disease (PH-LHD) corresponds to group two of pulmonary hypertension according to clinical classification. Haemodynamically, this group includes isolated post-capillary pulmonary hypertension (IpcPH) and combined post- and pre-capillary pulmonary hypertension (CpcPH). PH-LHD is defined by an mPAP > 20 mmHg and a PAWP > 15 mmHg, pulmonary vascular resistance (PVR) with a cut-off value of 2 Wood Units (WU) is used to differentiate between IpcPH and CpcPH. A PVR greater than 5 WU indicates a dominant precapillary component. PH-LHD is the most common form of pulmonary hypertension, the leading cause being left heart failure with preserved (HFpEF) or reduced ejection fraction (HFmrEF, HFrEF), valvular heart disease and, less commonly, congenital heart disease. The presence of pulmonary hypertension is associated with increased symptom burden and poorer outcome across the spectrum of left heart disease. Differentiating between group 1 pulmonary hypertension with cardiac comorbidities and PH-LHD, especially due to HFpEF, is a particular challenge. Therapeutically, no general recommendation for the use of PDE5 inhibitors in HFpEF-associated CpcPH can be made at this time. There is currently no reliable rationale for the use of PAH drugs in IpcPH, nor is therapy with endothelin receptor antagonists or prostacyclin analogues recommended for all forms of PH-LHD.
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Affiliation(s)
- Kai Helge Schmidt
- Zentrum für Kardiologie, Kardiologie I, Universitätsmedizin Mainz, Mainz, Deutschland
- Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin Mainz, Mainz, Deutschland
| | - Olympia Bikou
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, München, Deutschland
| | - Rüdiger Blindt
- Kardio Bremen, Rotes Kreuz Krankenhaus Bremen, Bremen, Deutschland
| | - Leonhard Bruch
- Klinik für Innere Medizin und Kardiologie, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Deutschland
| | | | | | - Stephan Holt
- Praxis am Steintor, Recklinghausen, Recklinghausen, Deutschland
| | - Dennis Ladage
- Klinik für Pneumologie, Kliniken Maria Hilf Mönchengladbach, Mönchengladbach, Deutschland
| | | | - Andreas Rieth
- Abteilung für Kardiologie, Kerckhoff-Klinik Bad Nauheim, Bad Nauheim, Deutschland
| | - Alexander Schmeisser
- Zentrum für Innere Medizin, Universitätsklinik für Kardiologie und Angiologie Magdeburg, Magdeburg, Deutschland
| | - Katharina Schnitzler
- Zentrum für Kardiologie, Kardiologie I, Universitätsmedizin Mainz, Mainz, Deutschland
| | - Stefan Stadler
- Klinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | | | - Athiththan Yogeswaran
- Department of Internal Medicine, Member of the German Center for Lung Research, Universities of Giessen and Marburg Lung Center, Justus-Liebig-University Giessen, Giessen, Deutschland
| | - Wolfgang M Kuebler
- Institute of Physiology, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
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Ali HR, Thomas J, Sahay S, Guha A. Management of pulmonary hypertension associated with valvular heart disease with angiotensin-receptor neprilysin inhibitor. Pulm Circ 2023; 13:e12303. [PMID: 37937122 PMCID: PMC10626127 DOI: 10.1002/pul2.12303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 08/23/2023] [Accepted: 09/20/2023] [Indexed: 11/09/2023] Open
Abstract
Pulmonary hypertension secondary to left-sided valvular disease (VHD-PH) is associated with high morbidity and mortality. Angiotensin-receptor neprilysin inhibitor (ARNI) is a novel pharmacotherapy, which reduces afterload with natriuresis and peripheral vasodilation. Our cases demonstrate that ARNI may also have a role in the treatment of combined pre- and postcapillary pulmonary hypertension that is independent of its effect on pulmonary capillary wedge pressure and cardiac output. Future prospective trials are needed to evaluate role of ARNIs in treatment of VHD-PH.
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Affiliation(s)
- Hyeon‐Ju Ryoo Ali
- Department of CardiologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | | | - Sandeep Sahay
- Department of PulmonologyHouston Methodist HospitalHoustonTexasUSA
| | - Ashrith Guha
- Department of CardiologyHouston Methodist HospitalHoustonTexasUSA
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Titz A, Mayer L, Appenzeller P, Müller J, Schneider SR, Tamm M, Darie AM, Guler SA, Aubert JD, Lador F, Stricker H, Fellrath JM, Pohle S, Lichtblau M, Ulrich S. Long-term outcome of patients with combined post- and pre-capillary pulmonary hypertension. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead069. [PMID: 37528902 PMCID: PMC10387509 DOI: 10.1093/ehjopen/oead069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/05/2023] [Accepted: 06/29/2023] [Indexed: 08/03/2023]
Abstract
Aims Pulmonary hypertension (PH) is a complex clinical condition, and left heart disease is the leading cause. Little is known about the epidemiology and prognosis of combined post- and pre-capillary PH (CpcPH). Methods and results This retrospective analysis of the Swiss PH Registry included incident patients with CpcPH registered from January 2001 to June 2019 at 13 Swiss hospitals. Patient baseline characteristics [age, sex, mean pulmonary artery pressure (mPAP), pulmonary artery wedge pressure (PAWP), pulmonary vascular resistance (PVR), and risk factors, including World Health Organization (WHO)-functional class (FC), 6 min walk distance (6MWD), and N-terminal pro-brain natriuretic peptide (NT-proBNP), treatment, days of follow-up, and events (death or loss to follow-up) at last visit] were analysed by Kaplan-Meier and Cox regression analyses. Two hundred and thirty-one patients (59.3% women, age 65 ± 12 years, mPAP 48 ± 11 mmHg, PAWP 21 ± 5 mmHg, PVR 7.2 ± 4.8 WU) were included. Survival analyses showed a significantly longer survival for women [hazard ratio (HR) 0.58 (0.38-0.89); P = 0.01] and a higher mortality risk for mPAP > 46 mmHg [HR 1.58 (1.03-2.43); P = 0.04] but no association with age or PVR. Patients stratified to high risk according to four-strata risk assessment had an increased mortality risk compared with patients stratified to low-intermediate risk [HR 2.44 (1.23-4.84); P = 0.01]. A total of 46.8% of CpcPH patients received PH-targeted pharmacotherapy; however, PH-targeted medication was not associated with longer survival. Conclusion Among patients with CpcPH, women and patients with an mPAP ≤46 mmHg survived longer. Furthermore, risk stratification by using non-invasively assessed risk factors, such as WHO-FC, 6MWD, and NT-proBNP, as proposed for pulmonary arterial hypertension, stratified survival in CpcPH, and might be helpful in the management of these patients.
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Affiliation(s)
- Anna Titz
- Department of Pulmonology, University Hospital Zurich, Rämistrasse 100, Zurich 8091, Switzerland
- Department of Pulmonology, University of Zurich, Zurich, Switzerland
| | - Laura Mayer
- Department of Pulmonology, University Hospital Zurich, Rämistrasse 100, Zurich 8091, Switzerland
- Department of Pulmonology, University of Zurich, Zurich, Switzerland
| | - Paula Appenzeller
- Department of Pulmonology, University Hospital Zurich, Rämistrasse 100, Zurich 8091, Switzerland
| | - Julian Müller
- Department of Pulmonology, University Hospital Zurich, Rämistrasse 100, Zurich 8091, Switzerland
- Department of Pulmonology, University of Zurich, Zurich, Switzerland
| | - Simon R Schneider
- Department of Pulmonology, University Hospital Zurich, Rämistrasse 100, Zurich 8091, Switzerland
- Department of Pulmonology, University of Zurich, Zurich, Switzerland
| | - Michael Tamm
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Andrei M Darie
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Sabina A Guler
- Department of Pulmonary Medicine and Department for BioMedical Research, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - John-David Aubert
- Department of Pulmonology, University Hospital Lausanne, Lausanne, Switzerland
| | - Frédéric Lador
- Department of Pulmonology, University Hospital Geneva, Geneva, Switzerland
| | - Hans Stricker
- Department of Angiology, Ospedale La Carità, Locarno, Switzerland
| | | | - Susanne Pohle
- Lung Center, Cantonal Hospital St Gallen, St Gallen, Switzerland
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Ltaief Z, Yerly P, Liaudet L. Pulmonary Hypertension in Left Heart Diseases: Pathophysiology, Hemodynamic Assessment and Therapeutic Management. Int J Mol Sci 2023; 24:9971. [PMID: 37373119 PMCID: PMC10298585 DOI: 10.3390/ijms24129971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
Pulmonary hypertension (PH) associated with left heart diseases (PH-LHD), also termed group 2 PH, represents the most common form of PH. It develops through the passive backward transmission of elevated left heart pressures in the setting of heart failure, either with preserved (HFpEF) or reduced (HFrEF) ejection fraction, which increases the pulsatile afterload of the right ventricle (RV) by reducing pulmonary artery (PA) compliance. In a subset of patients, progressive remodeling of the pulmonary circulation resulted in a pre-capillary phenotype of PH, with elevated pulmonary vascular resistance (PVR) further increasing the RV afterload, eventually leading to RV-PA uncoupling and RV failure. The primary therapeutic objective in PH-LHD is to reduce left-sided pressures through the appropriate use of diuretics and guideline-directed medical therapies for heart failure. When pulmonary vascular remodeling is established, targeted therapies aiming to reduce PVR are theoretically appealing. So far, such targeted therapies have mostly failed to show significant positive effects in patients with PH-LHD, in contrast to their proven efficacy in other forms of pre-capillary PH. Whether such therapies may benefit some specific subgroups of patients (HFrEF, HFpEF) with specific hemodynamic phenotypes (post- or pre-capillary PH) and various degrees of RV dysfunction still needs to be addressed.
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Affiliation(s)
- Zied Ltaief
- Service of Adult Intensive Care Medicine, University Hospital, 1011 Lausanne, Switzerland;
| | - Patrick Yerly
- Service of Cardiology, University Hospital, 1011 Lausanne, Switzerland;
| | - Lucas Liaudet
- Service of Adult Intensive Care Medicine, University Hospital, 1011 Lausanne, Switzerland;
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Martínez-Solano J, Ortiz-Bautista C, Gutiérrez-Ibañes E, García-Cosío MD, Sarnago-Cebada F, Díaz-Molina B, Pascual I, Gómez-Bueno M, Calviño-Santos R, Gómez-Hospital JA, García-Lara J, de la Fuente-Galán L, Mirabet-Pérez S, Martínez-Sellés M. Optical coherence tomography assessment of pulmonary vascular remodeling in advanced heart failure. The OCTOPUS-CHF study. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:312-321. [PMID: 36155847 DOI: 10.1016/j.rec.2022.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 09/06/2022] [Indexed: 04/29/2023]
Abstract
INTRODUCTION AND OBJECTIVES Pulmonary vascular remodeling is common among patients with advanced heart failure. Right heart catheterization is the gold standard to assess pulmonary hypertension, but is limited by indirect measurement assumptions, a steady-flow view, load-dependency, and interpretation variability. We aimed to assess pulmonary vascular remodeling with intravascular optical coherence tomography (OCT) and to study its correlation with hemodynamic data. METHODS This observational, prospective, multicenter study recruited 100 patients with advanced heart failure referred for heart transplant evaluation. All patients underwent right heart catheterization together with OCT evaluation of a subsegmentary pulmonary artery. RESULTS OCT could be performed and properly analyzed in 90 patients. Median age was 57.50 [interquartile range, 48.75-63.25] years and 71 (78.88%) were men. The most frequent underlying heart condition was nonischemic dilated cardiomyopathy (33 patients [36.66%]). Vascular wall thickness significantly correlated with mean pulmonary artery pressure, pulmonary vascular resistance, and transpulmonary gradient (R coefficient=0.42, 0.27 and 0.32 respectively). Noninvasive estimation of pulmonary artery systolic pressure, acceleration time, and right ventricle-pulmonary artery coupling also correlated with wall thickness (R coefficient of 0.42, 0.27 and 0.49, respectively). Patients with a wall thickness over 0.25mm had significantly higher mean pulmonary pressures (37.00 vs 25.00mmHg; P=.004) and pulmonary vascular resistance (3.44 vs 2.08 WU; P=.017). CONCLUSIONS Direct morphological assessment of pulmonary vascular remodeling with OCT is feasible and is significantly associated with classic hemodynamic parameters. This weak association suggests that structural remodeling does not fully explain pulmonary hypertension.
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Affiliation(s)
- Jorge Martínez-Solano
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Carlos Ortiz-Bautista
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Enrique Gutiérrez-Ibañes
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - María Dolores García-Cosío
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Fernando Sarnago-Cebada
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Beatriz Díaz-Molina
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Isaac Pascual
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Manuel Gómez-Bueno
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Majadahonda, Spain
| | - Ramón Calviño-Santos
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servizo de Cardioloxía, Complexo Hospitalario Universitario A Coruña, Coruña, Spain
| | - Joan Antoni Gómez-Hospital
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servei de Cardiologia, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Juan García-Lara
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Luis de la Fuente-Galán
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Sonia Mirabet-Pérez
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servei de Cardiologia, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Ciencias Biomédicas y de la Salud, Universidad Europea, Madrid, Spain
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Palevičiūtė E, Čelutkienė J, Šimbelytė T, Gumbienė L, Jurevičienė E, Zakarkaitė D, Čėsna S, Eichstaedt CA, Benjamin N, Grünig E. Safety and effectiveness of standardized exercise training in patients with pulmonary hypertension associated with heart failure with preserved ejection fraction (TRAIN-HFpEF-PH): study protocol for a randomized controlled multicenter trial. Trials 2023; 24:281. [PMID: 37072812 PMCID: PMC10114476 DOI: 10.1186/s13063-023-07297-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 04/05/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Left heart failure (HF) is characterized by an elevation in left-sided filling pressures, causing symptoms of dyspnea, impairing exercise capacity, and leading to pulmonary venous congestion and secondary pulmonary hypertension (PH). There is an increased incidence of PH associated with left heart disease, particularly with heart failure with preserved ejection fraction (HFpEF-PH). Treatment possibilities in HFpEF-PH are non-specific and very limited, thus additional pharmacological and non-pharmacological therapeutic strategies are needed. Various types of exercise-based rehabilitation programs have been shown to improve exercise capacity and quality of life (QoL) of HF and PH patients. However, no study focused on exercise training in the population of HFpEF-PH. This study is designed to investigate whether a standardized low-intensity exercise and respiratory training program is safe and may improve exercise capacity, QoL, hemodynamics, diastolic function, and biomarkers in patients with HFpEF-PH. METHODS A total of 90 stable patients with HFpEF-PH (World Health Organization functional class II-IV) will be randomized (1:1) to receive a 15-week specialized low-intensity rehabilitation program, including exercise and respiratory therapy and mental gait training, with an in-hospital start, or standard care alone. The primary endpoint of the study is a change in 6-min walk test distance; secondary endpoints are changes in peak exercise oxygen uptake, QoL, echocardiographic parameters, prognostic biomarkers, and safety parameters. DISCUSSION To date, no study has investigated the safety and efficacy of exercising specifically in the HFpEF-PH population. We believe that a randomized controlled multicenter trial, which protocol we are sharing in this article, will add important knowledge about the potential utility of a specialized low-intensity exercise and respiratory training program for HFpEF-PH and will be valuable in finding optimal treatment strategies for these patients. TRIAL REGISTRATION ClinicalTrials.gov NCT05464238. July 19, 2022.
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Affiliation(s)
- Eglė Palevičiūtė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Santariskiu-2, 08661, Vilnius, Lithuania.
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Santariskiu-2, 08661, Vilnius, Lithuania
| | - Toma Šimbelytė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Santariskiu-2, 08661, Vilnius, Lithuania
| | - Lina Gumbienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Santariskiu-2, 08661, Vilnius, Lithuania
| | | | - Diana Zakarkaitė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Santariskiu-2, 08661, Vilnius, Lithuania
| | - Sigitas Čėsna
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Santariskiu-2, 08661, Vilnius, Lithuania
| | - Christina A Eichstaedt
- Centre for Pulmonary Hypertension, German Center for Lung Research (DZL), Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Translational Lung Research Center Heidelberg (TLRC), Heidelberg, Germany
- Laboratory for Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, German Center for Lung Research (DZL), Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Translational Lung Research Center Heidelberg (TLRC), Heidelberg, Germany
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, German Center for Lung Research (DZL), Thoraxklinik Heidelberg gGmbH at Heidelberg University Hospital, Translational Lung Research Center Heidelberg (TLRC), Heidelberg, Germany
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Babu G, Annis JS, Garry JD, Freiberg MS, Hemnes AR, Brittain EL. Clinical features do not identify risk of progression from isolated postcapillary pulmonary hypertension to combined pre- and postcapillary pulmonary hypertension. Pulm Circ 2023; 13:e12249. [PMID: 37332851 PMCID: PMC10271598 DOI: 10.1002/pul2.12249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 04/25/2023] [Accepted: 05/30/2023] [Indexed: 06/20/2023] Open
Abstract
Pulmonary hypertension is a common sequelae of left heart failure and may present as isolated postcapillary pulmonary hypertension (Ipc-PH) or combined pre- and postcapillary pulmonary hypertension (Cpc-PH). Clinical features associated with progression from Ipc-PH to Cpc-PH have not yet been described. We extracted clinical data from patients who underwent right heart catheterizations (RHC) on two separate occasions. Ipc-PH was defined as mean pulmonary pressure >20 mmHg, pulmonary capillary wedge pressure >15 mmHg, and pulmonary vascular resistance (PVR) < 3 WU. Progression to Cpc-PH required an increase in PVR to ≥3 WU. We performed a retrospective cohort study with repeated assessments comparing subjects that progressed to Cpc-PH to subjects that remained with Ipc-PH. Of 153 patients with Ipc-PH at baseline who underwent a repeat RHC after a median of 0.7 years (IQR 0.2, 2.1), 33% (50/153) had developed Cpc-PH. In univariate analysis comparing the two groups at baseline, body mass index (BMI) and right atrial pressure were lower, while the prevalence of moderate or worse mitral regurgitation (MR) was higher among those who progressed. In age- and sex-adjusted multivariable analysis, only BMI (OR 0.94, 95% CI 0.90-0.99, p = 0.017, C = 0.655) and moderate or worse MR (OR 3.00, 95% CI 1.37-6.60, p = 0.006, C = 0.654) predicted progression, but with poor discriminatory power. This study suggests that clinical features alone cannot distinguish patients at risk for development of Cpc-PH and support the need for molecular and genetic studies to identify biomarkers of progression.
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Affiliation(s)
- Gautam Babu
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jeffrey S. Annis
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jonah D. Garry
- Department of Medicine, Division of Cardiovascular MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Matthew S. Freiberg
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Anna R. Hemnes
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Evan L. Brittain
- Department of Medicine, Division of Cardiovascular MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Division of Cardiovascular Medicine, Vanderbilt Translational and Clinical Research CenterVanderbilt University Medical CenterNashvilleTennesseeUSA
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9
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Fayyaz AU, Sabbah MS, Dasari S, Griffiths LG, DuBrock HM, Wang Y, Charlesworth MC, Borlaug BA, Jenkins SM, Edwards WD, Redfield MM. Histologic and proteomic remodeling of the pulmonary veins and arteries in a porcine model of chronic pulmonary venous hypertension. Cardiovasc Res 2023; 119:268-282. [PMID: 35022664 DOI: 10.1093/cvr/cvac005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 11/15/2021] [Accepted: 01/10/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS In heart failure (HF), pulmonary venous hypertension (PVH) produces pulmonary hypertension (PH) with remodeling of pulmonary veins (PV) and arteries (PA). In a porcine PVH model, we performed proteomic-based bioinformatics to investigate unique pathophysiologic mechanisms mediating PA and PV remodeling. METHODS AND RESULTS Large PV were banded (PVH, n = 10) or not (Sham, n = 9) in piglets. At sacrifice, PV and PA were perfusion labelled for vessel-specific histology and proteomics. The PA and PV were separately sampled with laser-capture micro-dissection for mass spectrometry. Pulmonary vascular resistance [Wood Units; 8.6 (95% confidence interval: 6.3, 12.3) vs. 2.0 (1.7, 2.3)] and PA [19.9 (standard error of mean, 1.1) vs. 10.3 (1.1)] and PV [14.2 (1.2) vs. 7.6 (1.1)] wall thickness/external diameter (%) were increased in PVH (P < 0.05 for all). Similar numbers of proteins were identified in PA (2093) and PV (2085) with 94% overlap, but biological processes differed. There were more differentially expressed proteins (287 vs. 161), altered canonical pathways (17 vs. 3), and predicted upstream regulators (PUSR; 22 vs. 6) in PV than PA. In PA and PV, bioinformatics indicated activation of the integrated stress response and mammalian target of rapamycin signalling with dysregulated growth. In PV, there was also activation of Rho/Rho-kinase signalling with decreased actin cytoskeletal signalling and altered tight and adherens junctions, ephrin B, and caveolae-mediated endocytosis signalling; all indicating disrupted endothelial barrier function. Indeed, protein biomarkers and the top PUSR in PV (transforming growth factor-beta) suggested endothelial to mesenchymal transition in PV. Findings were similar in human autopsy specimens. CONCLUSION These findings provide new therapeutic targets to oppose pulmonary vascular remodeling in HF-related PH.
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Affiliation(s)
- Ahmed U Fayyaz
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Michael S Sabbah
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Surendra Dasari
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Leigh G Griffiths
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Hilary M DuBrock
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Ying Wang
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - M Cristine Charlesworth
- Molecular Genome Facility Proteomics Core, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Sarah M Jenkins
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - William D Edwards
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Margaret M Redfield
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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10
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Segovia F, Garcia H, Alkhateeb H, Mukherjee D, Nickel N. Updates in the Pharmacotherapy of Pulmonary Hypertension in Patients with Heart Failure with Preserved Ejection Fraction. Cardiovasc Hematol Disord Drug Targets 2023; 23:215-225. [PMID: 37921162 DOI: 10.2174/011871529x258234230921112507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/24/2023] [Accepted: 08/24/2023] [Indexed: 11/04/2023]
Abstract
Pulmonary hypertension (PH) associated with left heart disease (LHD) is a complex cardiopulmonary condition where a variable degree of pulmonary congestion, arterial vasoconstriction and vascular remodeling can lead to PH and right heart strain. Right heart dysfunction has a significant prognostic impact on these patients. Therefore, preserving right ventricular (RV) function is an important treatment goal. However, the treatment of PH in patients with left heart disease has produced conflicting evidence. The transition from pure LHD to LHD with PH is a continuum and clinically challenging. The heart failure with preserved ejection fraction (HFpEF) patient population is heterogeneous when it comes to PH and RV function. Appropriate clinical and hemodynamic phenotyping of patients with HFpEF and concomitant PH is paramount to making the appropriate treatment decision. This manuscript will summarize the current evidence for the use of pulmonary arterial vasodilators in patients with HFpEF.
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Affiliation(s)
- Fernando Segovia
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Hernando Garcia
- Pulmonary and Critical Care, Mount Sinai Medical Center, Miami, Florida, USA
| | - Haider Alkhateeb
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Nils Nickel
- Division of Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
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11
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 394] [Impact Index Per Article: 394.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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12
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Baratto C, Caravita S, Corbetta G, Soranna D, Zambon A, Dewachter C, Gavazzoni M, Heilbron F, Tomaselli M, Radu N, Perelli FP, Perego GB, Vachiéry JL, Parati G, Badano LP, Muraru D. Impact of severe secondary tricuspid regurgitation on rest and exercise hemodynamics of patients with heart failure and a preserved left ventricular ejection fraction. Front Cardiovasc Med 2023; 10:1061118. [PMID: 36937944 PMCID: PMC10014840 DOI: 10.3389/fcvm.2023.1061118] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/06/2023] [Indexed: 03/06/2023] Open
Abstract
Background Both secondary tricuspid regurgitation (STR) and heart failure with preserved ejection fraction (HFpEF) are relevant public health problems in the elderly population, presenting with potential overlaps and sharing similar risk factors. However, the impact of severe STR on hemodynamics and cardiorespiratory adaptation to exercise in HFpEF remains to be clarified. Aim To explore the impact of STR on exercise hemodynamics and cardiorespiratory adaptation in HFpEF. Methods We analyzed invasive hemodynamics and gas-exchange data obtained at rest and during exercise from HFpEF patients with severe STR (HFpEF-STR), compared with 1:1 age-, sex-, and body mass index (BMI)- matched HFpEF patients with mild or no STR (HFpEF-controls). Results Twelve HFpEF with atrial-STR (mean age 72 years, 92% females, BMI 28 Kg/m2) and 12 HFpEF-controls patients were analyzed. HFpEF-STR had higher (p < 0.01) right atrial pressure than HFpEF-controls both at rest (10 ± 1 vs. 5 ± 1 mmHg) and during exercise (23 ± 2 vs. 14 ± 2 mmHg). Despite higher pulmonary artery wedge pressure (PAWP) at rest in HFpEF-STR than in HFpEF-controls (17 ± 2 vs. 11 ± 2, p = 0.04), PAWP at peak exercise was no more different (28 ± 2 vs. 29 ± 2). Left ventricular transmural pressure and cardiac output (CO) increased less in HFpEF-STR than in HFpEF-controls (interaction p-value < 0.05). This latter was due to lower stroke volume (SV) values both at rest (48 ± 9 vs. 77 ± 9 mL, p < 0.05) and at peak exercise (54 ± 10 vs. 93 ± 10 mL, p < 0.05). Despite these differences, the two groups of patients laid on the same oxygen consumption isophlets because of the increased peripheral oxygen extraction in HFpEF-STR (p < 0.01). We found an inverse relationship between pulmonary vascular resistance and SV, both at rest and at peak exercise (R 2 = 0.12 and 0.19, respectively). Conclusions Severe STR complicating HFpEF impairs SV and CO reserve, leading to pulmonary vascular de-recruitment and relative left heart underfilling, undermining the typical HFpEF pathophysiology.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Sergio Caravita
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Bergamo, Italy
- *Correspondence: Sergio Caravita
| | - Giorgia Corbetta
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Davide Soranna
- Biostatistic Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Antonella Zambon
- Biostatistic Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Statistics and Quantitative Methods, Università di Milano-Bicocca, Milan, Italy
| | - Céline Dewachter
- Department of Cardiology, Hôpital Académique Erasme, Cliniques Universitaires de Bruxelles, Brussels, Belgium
| | - Mara Gavazzoni
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Francesca Heilbron
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Michele Tomaselli
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Noela Radu
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Francesco Paolo Perelli
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | | | - Jean-Luc Vachiéry
- Department of Cardiology, Hôpital Académique Erasme, Cliniques Universitaires de Bruxelles, Brussels, Belgium
| | - Gianfranco Parati
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Luigi P. Badano
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Denisa Muraru
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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13
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Martínez-Solano J, Gutiérrez-Ibañes E, Ortiz-Bautista C, García-Cosío MD, Sarnago-Cebada F, Díaz-Molina B, Pascual I, Oteo-Domínguez JF, Gómez-Bueno M, Calviño-Santos R, Crespo-Leiro MG, Gómez-Hospital JA, Díez-López C, García-Lara J, Garrido-Bravo IP, de la Fuente-Galán L, López-Díaz J, Mirabet-Pérez S, Martínez-Sellés M. Pulmonary Vascular Remodeling and Prognosis in Patients Evaluated for Heart Transplantation: Insights from the OCTOPUS-CHF Study. J Cardiovasc Dev Dis 2022; 9:jcdd9120439. [PMID: 36547436 PMCID: PMC9785366 DOI: 10.3390/jcdd9120439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE In patients with advanced heart failure, the intravascular optical coherence tomography (OCT) of subsegmental pulmonary artery measurements is correlated with right heart catheterization parameters. Our aim was to study the prognostic value of pulmonary OCT, right heart catheterization data, and the echocardiographic estimation of pulmonary pressure in patients studied for elective heart transplants. METHODS This research is an observational, prospective, multicenter study involving 90 adults with a one-year follow-up. RESULTS A total of 10 patients (11.1%) died due to worsening heart failure before heart transplantation, 50 underwent a heart transplant (55.6%), and 9 died in the first year after the transplant. The patients with and without events (mortality or heart failure-induced hospitalization) had similar data regarding echocardiography, right heart catheterization, and pulmonary OCT (with a median estimated pulmonary artery systolic pressure of 42.0 mmHg, interquartile range (IQR) of 30.3-50.0 vs. 47.0 mmHg, IQR 34.6-59.5 and p = 0.79, median pulmonary vascular resistance of 2.2 Wood units, IQR 1.3-3.7 vs. 2.0 Wood units, IQR 1.4-3.2 and p = 0.99, and a median pulmonary artery wall thickness of 0.2 ± 0.5 mm vs. 0.2 ± 0.6 mm and p = 0.87). CONCLUSION Pulmonary vascular remodeling (evaluated with echocardiography, right heart catheterization, and pulmonary OCT) was not associated with prognosis in a selected sample of adults evaluated for elective heart transplants. Pulmonary OCT is safe and feasible for the evaluation of these patients.
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Affiliation(s)
- Jorge Martínez-Solano
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), 28007 Madrid, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
| | - Enrique Gutiérrez-Ibañes
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), 28007 Madrid, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
| | - Carlos Ortiz-Bautista
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), 28007 Madrid, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
| | - María Dolores García-Cosío
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), 28041 Madrid, Spain
| | - Fernando Sarnago-Cebada
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), 28041 Madrid, Spain
| | - Beatriz Díaz-Molina
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | - Isaac Pascual
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | - Juan Francisco Oteo-Domínguez
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain
| | - Manuel Gómez-Bueno
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain
| | - Ramón Calviño-Santos
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servizo de Cardioloxía, Complexo Hospitalario Universitario A Coruña, 15006 A Coruña, Spain
| | - María G Crespo-Leiro
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servizo de Cardioloxía, Complexo Hospitalario Universitario A Coruña, 15006 A Coruña, Spain
| | - Joan Antoni Gómez-Hospital
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servei de Cardiologia, Hospital Universitari de Bellvitge, 08907 Barcelona, Spain
| | - Carles Díez-López
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servei de Cardiologia, Hospital Universitari de Bellvitge, 08907 Barcelona, Spain
| | - Juan García-Lara
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Iris P Garrido-Bravo
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Luis de la Fuente-Galán
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Javier López-Díaz
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Sonia Mirabet-Pérez
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Servei de Cardiologia, Hospital Universitario de la Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), 28007 Madrid, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28026 Madrid, Spain
- Facultad de Ciencias Biomédicas y de la Salud, Universidad Europea, 28670 Madrid, Spain
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14
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Martínez-Solano J, Ortiz-Bautista C, Gutiérrez-Ibañes E, García-Cosío MD, Sarnago-Cebada F, Díaz-Molina B, Pascual I, Gómez-Bueno M, Calviño-Santos R, Gómez-Hospital JA, García-Lara J, de la Fuente-Galán L, Mirabet-Pérez S, Martínez-Sellés M. Evaluación mediante OCT del remodelado vascular pulmonar en insuficiencia cardiaca avanzada. Estudio OCTOPUS-CHF. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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15
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 942] [Impact Index Per Article: 471.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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16
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Baratto C, Caravita S, Soranna D, Dewachter C, Bondue A, Zambon A, Badano LP, Parati G, Vachiéry J. An updated meta-analysis of hemodynamics markers of prognosis in patients with pulmonary hypertension due to left heart disease. Pulm Circ 2022; 12:e12145. [PMID: 36568693 PMCID: PMC9768568 DOI: 10.1002/pul2.12145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/20/2022] [Accepted: 07/14/2022] [Indexed: 12/27/2022] Open
Abstract
Pulmonary hypertension (PH) is associated with a poor prognosis in left heart disease (LHD). We sought to provide an updated analysis on the association of hemodynamic variables, such as pulmonary vascular resistance (PVR), pulmonary artery compliance (PAC), and diastolic pressure gradient (DPG), with prognosis in PH-LHD, through a systematic literature review. Sixteen articles were identified, including 9600 patients with LHD, heterogeneous in terms of age, sex, and etiology of cardiac disease. In this large population, PVR (hazard ratio [HR], 1.07; 95% confidence interval [CI]: 1.05-1.0), DPG (HR, 1.02; 95% CI: 1.01-1.02) and PAC (HR, 0.76; 95% CI: 0.69-0.84) were associated with an increased risk of adverse outcome, albeit with a less solid performance of DPG. Similar results were found when hemodynamic variables were analyzed according to the thresholds commonly applied in clinical practice, or subdividing cohorts according to the underlying LHD. Furthermore, cumulative metanalysis indicated that these results are consistently stable since 2018. Thus, PVR, DPG and PAC have an established prognostic value in PH-LHD. These results are consistent through the years and unlikely to change with further studies.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCSOspedale San LucaMilanoItaly
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCSOspedale San LucaMilanoItaly,Department of Management, Information and Production EngineeringUniversity of BergamoDalmine (BG)Italy
| | - Davide Soranna
- IRCCS Istituto Auxologico ItalianoBiostatistics UnitMilanItaly
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de BruxellesHôpital Académique ErasmeBruxellesBelgium
| | - Antoine Bondue
- Department of Cardiology, Cliniques Universitaires de BruxellesHôpital Académique ErasmeBruxellesBelgium
| | - Antonella Zambon
- IRCCS Istituto Auxologico ItalianoBiostatistics UnitMilanItaly,Department of Statistic and Quantitative MethodsUniversity of Milano‐BicoccaMilanItaly
| | - Luigi P. Badano
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCSOspedale San LucaMilanoItaly,Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanoItaly
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCSOspedale San LucaMilanoItaly,Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanoItaly
| | - Jean‐Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de BruxellesHôpital Académique ErasmeBruxellesBelgium
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17
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Omote K, Sorimachi H, Obokata M, Reddy YNV, Verbrugge FH, Omar M, DuBrock HM, Redfield MM, Borlaug BA. Pulmonary vascular disease in pulmonary hypertension due to left heart disease: pathophysiologic implications. Eur Heart J 2022; 43:3417-3431. [PMID: 35796488 PMCID: PMC9794188 DOI: 10.1093/eurheartj/ehac184] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 02/10/2022] [Accepted: 03/28/2022] [Indexed: 12/31/2022] Open
Abstract
AIMS Pulmonary hypertension (PH) and pulmonary vascular disease (PVD) are common and associated with adverse outcomes in left heart disease (LHD). This study sought to characterize the pathophysiology of PVD across the spectrum of PH in LHD. METHODS AND RESULTS Patients with PH-LHD [mean pulmonary artery (PA) pressure >20 mmHg and PA wedge pressure (PAWP) ≥15 mmHg] and controls free of PH or LHD underwent invasive haemodynamic exercise testing with simultaneous echocardiography, expired air and blood gas analysis, and lung ultrasound in a prospective study. Patients with PH-LHD were divided into isolated post-capillary PH (IpcPH) and PVD [combined post- and pre-capillary PH (CpcPH)] based upon pulmonary vascular resistance (PVR <3.0 or ≥3.0 WU). As compared with controls (n = 69) and IpcPH-LHD (n = 55), participants with CpcPH-LHD (n = 40) displayed poorer left atrial function and more severe right ventricular (RV) dysfunction at rest. With exercise, patients with CpcPH-LHD displayed similar PAWP to IpcPH-LHD, but more severe RV-PA uncoupling, greater ventricular interaction, and more severe impairments in cardiac output, O2 delivery, and peak O2 consumption. Despite higher PVR, participants with CpcPH developed more severe lung congestion compared with both IpcPH-LHD and controls, which was associated lower arterial O2 tension, reduced alveolar ventilation, decreased pulmonary O2 diffusion, and greater ventilation-perfusion mismatch. CONCLUSIONS Pulmonary vascular disease in LHD is associated with a distinct pathophysiologic signature marked by greater exercise-induced lung congestion, arterial hypoxaemia, RV-PA uncoupling, ventricular interdependence, and impairment in O2 delivery, impairing aerobic capacity. Further study is required to identify novel treatments targeting the pulmonary vasculature in PH-LHD.
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Affiliation(s)
- Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Frederik H Verbrugge
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Massar Omar
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Margaret M Redfield
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
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18
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Moles VM, Grafton G. Pulmonary Hypertension in Heart Failure with Preserved Ejection Fraction. Cardiol Clin 2022; 40:533-540. [DOI: 10.1016/j.ccl.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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19
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Gong C, Guo X, Wan K, Chen C, Chen X, Guo J, He J, Yin L, Wen B, Pu S, Chen Y. Corrected MRI Pulmonary Transit Time for Identification of Combined Precapillary and Postcapillary Pulmonary Hypertension in Patients With Left Heart Disease. J Magn Reson Imaging 2022; 57:1518-1528. [PMID: 37021578 DOI: 10.1002/jmri.28386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The identification of combined precapillary and postcapillary pulmonary hypertension (CpcPH) in patients with pulmonary hypertension (PH) due to left heart disease (LHD) can influence therapy and outcome and is currently based on invasively determined hemodynamic parameters. PURPOSE To investigate the diagnostic value of MRI-derived corrected pulmonary transit time (PTTc) in PH-LHD sub-grouped according to hemodynamic phenotypes. STUDY TYPE Prospective observational study. POPULATION A total of 60 patients with PH-LHD (18 with isolated postcapillary PH [IpcPH] and 42 with CpcPH), and 33 healthy subjects. FIELD STRENGTH/SEQUENCE A 3.0 T/balanced steady-state free precession cine and gradient echo-train echo planar pulse first-pass perfusion. ASSESSMENT In patients, right heart catheterization (RHC) and MRI were performed within 30 days. Pulmonary vascular resistance (PVR) was used as the diagnostic "reference standard." The PTTc was calculated as the time interval between the peaks of the biventricular signal-intensity/time curve and corrected for heart rate. PTTc was compared between patient groups and healthy subjects and its relationship to PVR assessed. The diagnostic accuracy of PTTc for distinguishing IpcPH and CpcPH was determined. STATISTICAL TESTS Student's t-test, Mann-Whitney U-test, linear and logistic regression analysis, and receiver-operating characteristic curves. Significance level: P < 0.05. RESULTS PTTc was significantly prolonged in CpcPH compared with IpcPH and normal controls (17.28 ± 7.67 vs. 8.82 ± 2.55 vs. 6.86 ± 2.11 seconds), and in IpcPH compared with normal controls (8.82 ± 2.55 vs. 6.86 ± 2.11 seconds). Prolonged PTTc was significantly associated with increased PVR. Furthermore, PTTc was a significantly independent predictor of CpcPH (odds ratio: 1.395, 95% confidence interval: 1.071-1.816). The area under curve was 0.852 at a cut-off value of 11.61 seconds for PTTc to distinguish between CpcPH and IpcPH (sensitivity 71.43% and specificity 94.12%). DATA CONCLUSION PTTc may be used to identify CpcPH. Our findings have potential to improve selection for invasive RHC for PH-LHD patients. EVIDENCE LEVEL 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Chao Gong
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Xinli Guo
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Ke Wan
- Department of Geriatrics, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Chen Chen
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Xiaoling Chen
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Jiajun Guo
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Juan He
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Lidan Yin
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Bi Wen
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Shoufang Pu
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Yucheng Chen
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
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20
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Anderson JJ, Lau EM. Pulmonary Hypertension Definition, Classification, and Epidemiology in Asia. JACC. ASIA 2022; 2:538-546. [PMID: 36624795 PMCID: PMC9823284 DOI: 10.1016/j.jacasi.2022.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 04/05/2022] [Accepted: 04/16/2022] [Indexed: 01/12/2023]
Abstract
Pulmonary hypertension (PH) is caused by a range of conditions and is important to recognize as it is associated with increased mortality. Pulmonary arterial hypertension refers to a group of PH subtypes affecting the distal pulmonary arteries for which effective treatment is available. The hemodynamic definition of pulmonary arterial hypertension has recently changed which may lead to greater case recognition and earlier treatment. The prevalence of specific PH etiologies may differ depending on geographic region. PH caused by left heart disease is the most common cause of PH worldwide. In Asia, there is greater proportion of congenital heart disease- and connective tissue disease- (especially systemic lupus erythematosus) related PH relative to the West. This review summarizes the definition, classification, and epidemiology of PH as it pertains to Asia.
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Affiliation(s)
- James J. Anderson
- Respiratory Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia,School of Medicine, Griffith University, Southport, Queensland, Australia,Address for correspondence: Dr Anderson, Respiratory Department, Sunshine Coast University Hospital, 6 Doherty Street, Birtinya, 4575, Queensland 4575, Australia.
| | - Edmund M. Lau
- Respiratory Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia,Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
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21
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Kovacs G, Olschewski H. The definition of pulmonary hypertension: history, practical implications and current controversies. Breathe (Sheff) 2022; 17:210076. [PMID: 35035548 PMCID: PMC8753640 DOI: 10.1183/20734735.0076-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/19/2021] [Indexed: 01/14/2023] Open
Abstract
The definition of pulmonary hypertension (PH) is based on a growing body of evidence and represents the result of ongoing discussions within the PH community over the past 50 years. In 2018, the most recent World Symposium on Pulmonary Hypertension introduced significant changes in the definition of PH by lowering the mean pulmonary arterial pressure threshold to >20 mmHg and (re)introducing the pulmonary vascular resistance ≥3 WU cut-off for all forms of pre-capillary PH. These changes and their potential clinical impact have been the subject of lively discussions in the community and some important questions and controversies have been identified. In this review we aim to present the development of the definition of PH over the past decades and discuss the main arguments that led to relevant modifications. In addition, we address the practical implications of the most recent changes and controversies that still exist. The definitions of PH and PAH reflect the upper limit of normal haemodynamic values, their prognostic relevance and practical considerations. With appropriate clinical context they represent the cornerstone of PH diagnosis and clinical decision making.https://bit.ly/3gRSyWz
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Affiliation(s)
- Gabor Kovacs
- Dept of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria.,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Horst Olschewski
- Dept of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria.,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
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22
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Inaccuracy of a non-invasive estimation of pulmonary vascular resistance assessed by cardiovascular magnetic resonance in heart failure patients. Sci Rep 2021; 11:16597. [PMID: 34400680 PMCID: PMC8368081 DOI: 10.1038/s41598-021-95897-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/26/2021] [Indexed: 11/15/2022] Open
Abstract
Pulmonary vascular resistance (PVR) is a marker of pulmonary vascular remodeling. A non-invasive model assessed by cardiovascular magnetic resonance (CMR) has been proposed to estimate PVR. However, its accuracy has not yet been evaluated in patients with heart failure. We prospectively included 108 patients admitted with acute heart failure (AHF), in whom a right heart catheterization (RHC) and CMR were performed at the same day. PVR was estimated by CMR applying the model: PVR = 19.38 − [4.62 × Ln pulmonary artery average velocity (in cm/s)] − [0.08 × right ventricle ejection fraction (in %)], and by RHC using standard formulae. The median age of the cohort was 67 years (interquartile range 58–73), and 34% were females. The median of PVR assessed by RHC and CMR were 2.2 WU (1.5–4) and 5 WU (3.4–7), respectively. We found a weak correlation between invasive PVR and PVR assessed by CMR (Spearman r = 0.21, p = 0.02). The area under the ROC curve for PVR assessed by CMR to detect PVR ≥ 3 WU was 0.57, 95% confidence interval (CI): 0.47–0.68. In patients with AHF, the non-invasive estimation of PVR using CMR shows poor accuracy, as well as a limited capacity to discriminate increased PVR values.
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23
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Macera F, Vachiéry JL. Management of Pulmonary Hypertension in Left Heart Disease. Methodist Debakey Cardiovasc J 2021; 17:115-123. [PMID: 34326931 PMCID: PMC8298119 DOI: 10.14797/rkqn5397] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 12/24/2022] Open
Abstract
Pulmonary hypertension due to left heart diseases (PH-LHD) is the most prevalent
form of pulmonary hypertension. It frequently complicates heart failure with
reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF) and
negatively impacts prognosis, particularly when a precapillary component is
present. PH-LHD is distinctive from pulmonary arterial hypertension (PAH) even though both
conditions may share some common characteristics. In addition, the mechanisms
involved in the development of a precapillary component are yet to be fully
clarified, in particular in PH due to HFpEF. Several studies have been exploring PAH pathways as potential therapies for
PH-LHD, but no PAH-approved drug has demonstrated efficacy in PH-LHD. Rather,
some classes of drugs, such as endothelin-receptor antagonists or
prostacycline-analogues, have been found to be harmful in patients with HF.
Therefore, at present, the only established treatments for PH-LHD are those that
target the heart as recommended in the international guidelines for HF. Based on
current knowledge, off-label prescription of PAH-approved drugs in PH-LHD
patients must be strongly discouraged.
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Affiliation(s)
- Francesca Macera
- Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium.,Niguarda Ca' Granda Hospital, Milan, Italy
| | - Jean-Luc Vachiéry
- Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
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24
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Lu J, Chen R, Liu H, Hong C. Right atrial area to left atrial area ratio, a diagnostic and prognostic parameter worth studying in pulmonary hypertension due to left heart disease. Int J Cardiol 2021; 338:238. [PMID: 34118324 DOI: 10.1016/j.ijcard.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/07/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Jianmin Lu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510010, China
| | - Riken Chen
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510010, China
| | - Haimin Liu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510010, China
| | - Cheng Hong
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510010, China.
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25
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Pfeuffer-Jovic E, Weiner S, Wilkens H, Schmitt D, Frantz S, Held M. Impact of the new definition of pulmonary hypertension according to world symposium of pulmonary hypertension 2018 on diagnosis of post-capillary pulmonary hypertension. Int J Cardiol 2021; 335:105-110. [PMID: 33823213 DOI: 10.1016/j.ijcard.2021.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 03/06/2021] [Accepted: 04/02/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND The World Symposium on Pulmonary Hypertension (WSPH) in 2018 recommended new definitions of pulmonary hypertension (PH). We investigated the impact of the updated definition on prevalence of PH due to left heart disease (PH-LHD). METHODS The data of right heart catheterizations in patients with suspected PH-LHD between January 2008 and July 2015 was retrospectively analyzed applying different definitions. The number of patients diagnosed by the updated WSPH hemodynamic criteria of a mean pulmonary artery pressure (mPAP) > 20 mmHg was compared to the number of patients using mPAP ≥ 25 mmHg. The differentiation between patients with isolated post-capillary (Ipc) and combined post-capillary and pre-capillary (Cpc) PH was analyzed comparing the ESC/ERS guidelines, the recommendation of Cologne Consensus Conference (CCC) and WSPH. RESULTS Of the 726 patients with a suspected PH, 58 patients met the diagnostic criteria of the ESC/ERS guidelines for PH-LHD with 32.8% Ipc-cases, 34.4% Cpc-PH-cases and 32.8% unclassifiable cases. Overall, 58 patients were diagnosed by the CCC criteria, with 34.5% classified as Cpc-PH and 65.5% as Icp-PH. Using the criteria of WSPH, the number of PH-LHD rose by one patient. According to the new definition, 64.4% of the patients were classified as Cpc-PH and had a significantly higher right to left atrial area (RA/LA) ratio than Ipc-PH patients. CONCLUSION Applying the new recommendation, the number of diagnosed patients with PH-LHD increases marginally. There is, however, a relevant shift in the number of Cpc-PH cases. An elevated RA/LA ratio might help to identify patients for invasive diagnostic work-up.
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Affiliation(s)
- Elena Pfeuffer-Jovic
- Department of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital, Central Clinic Würzburg, Academic Teaching Hospital of the Julius Maximilian University of Würzburg, Würzburg, Germany.
| | - Simon Weiner
- Department of Diagnostic and Interventional Neuroradiology, Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Heinrike Wilkens
- Department of Internal Medicine V, Pulmonology, Allergology, Respiratory Intensive Care Medicine, Saarland University, Homburg Saar, Germany
| | - Delia Schmitt
- Department of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital, Central Clinic Würzburg, Academic Teaching Hospital of the Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Stefan Frantz
- Department of Internal Medicine I, Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Matthias Held
- Department of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital, Central Clinic Würzburg, Academic Teaching Hospital of the Julius Maximilian University of Würzburg, Würzburg, Germany
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26
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Ibe T, Wada H, Sakakura K, Ugata Y, Maki H, Yamamoto K, Seguchi M, Taniguchi Y, Jinnouchi H, Momomura SI, Fujita H. Combined pre- and post-capillary pulmonary hypertension: The clinical implications for patients with heart failure. PLoS One 2021; 16:e0247987. [PMID: 33651852 PMCID: PMC7924774 DOI: 10.1371/journal.pone.0247987] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/17/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The prognostic implications of combined pre- and post-capillary pulmonary hypertension (Cpc-PH) in patients with pulmonary hypertension due to left heart disease (PH-LHD) remain controversial. The aim of this retrospective study was to evaluate the new PH-LHD criteria, recommended by the 6th World Symposium on Pulmonary Hypertension and to determine the prognostic value of Cpc-PH. METHODS A total of 701 patients with symptomatic heart failure who had undergone right-heart catheterization were divided into the following four groups: (i) Isolated post-capillary PH (Ipc-PH) group; mean pulmonary artery pressure (mPAP) >20 mmHg, pulmonary artery wedge pressure (PAWP) >15 mmHg, and pulmonary vascular resistance (PVR) <3 Wood units (WU) (ii) Cpc-PH group; mPAP >20 mmHg, PAWP >15 mmHg, and PVR ≥3 WU (iii) borderline-PH group; mPAP >20 mmHg and PAWP ≤15 mmHg (iv) non-PH group; mPAP ≤20 mmHg. Multivariate Cox hazard analysis was used to investigate whether Cpc-PH was associated with cardiac outcomes. RESULTS The study subjects were allocated into the Ipc-PH (n = 268), Cpc-PH (n = 54), borderline-PH (n = 112), or non-PH (n = 267) groups. The Cpc-PH group was associated significantly with adverse cardiac events even after adjustment for clinically relevant confounding factors for heart failure prognosis (vs. non-PH group: HR 2.98 [95% CI 1.81-4.90], P <0.001; vs. Ipc-PH group: HR: 1.92 [95% CI 1.19-3.08], P = 0.007). CONCLUSIONS The new definitions of PH-LHD stratified patients into 4 categories. Long-term clinical outcomes were significantly different between the four categories, with Cpc-PH having the worst cardiac outcomes.
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Affiliation(s)
- Tatsuro Ibe
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroshi Wada
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
- * E-mail:
| | - Kenichi Sakakura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yusuke Ugata
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hisataka Maki
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kei Yamamoto
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Masaru Seguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yousuke Taniguchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroyuki Jinnouchi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shin-ichi Momomura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hideo Fujita
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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27
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Lange TJ, Borst M, Ewert R, Halank M, Klose H, Leuchte H, Meyer FJ, Seyfarth HJ, Skowasch D, Wilkens H, Held M. [Current Aspects of Definition and Diagnosis of Pulmonary Hypertension]. Pneumologie 2020; 74:847-863. [PMID: 32663892 DOI: 10.1055/a-1199-1548] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
At the 6th World Symposium on Pulmonary Hypertension (WSPH), which took place from February 27 until March 1, 2018 in Nice, scientific progress over the past 5 years in the field of pulmonary hypertension (PH) was presented by 13 working groups. The results of the discussion were published as proceedings towards the end of 2018. One of the major changes suggested by the WSPH was the lowering of the diagnostic threshold for PH from ≥ 25 to > 20 mmHg mean pulmonary arterial pressure, measured by right heart catheterization at rest. In addition, the pulmonary vascular resistance was introduced into the definition of PH, which underlines the importance of cardiac output determination at the diagnostic right heart catheterization.In this article, we discuss the rationale and possible consequences of a changed PH definition in the context of the current literature. Further, we provide a current overview on non-invasive and invasive methods for diagnosis, differential diagnosis, and prognosis of PH, including exercise tests.
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Affiliation(s)
- T J Lange
- Uniklinik Regensburg, Klinik für Innere Medizin II, Bereich Pneumologie, Regensburg
| | - M Borst
- Medizinische Klinik I, Caritas-Krankenhaus, Bad Mergentheim
| | - R Ewert
- Pneumologie, Uniklinik Greifswald, Greifwald
| | - M Halank
- Universitätsklinikum Carl Gustav Carus, Medizinische Klinik 1, Bereich Pneumologie, Dresden
| | - H Klose
- Universitätsklinikum Hamburg-Eppendorf, Abteilung für Pneumologie, Hamburg
| | - H Leuchte
- Klinik der Barmherzigen Schwestern, Krankenhaus Neuwittelsbach, Lehrkrankenhaus der LMU München, München
| | - F J Meyer
- Lungenzentrum München (Bogenhausen-Harlaching), München Klinik gGmbH, München
| | - H-J Seyfarth
- Bereich Pneumologie, Universitätsklinikum Leipzig, Leipzig
| | - D Skowasch
- Universitätsklinikum Bonn, Medizinische Klinik II, Sektion Pneumologie, Bonn
| | - H Wilkens
- Klinik für Innere Medizin V, Universitätsklinikum des Saarlandes, Homburg
| | - M Held
- Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Klinikum Würzburg Mitte, Standort Missioklinik, Würzburg
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28
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Sanchez Palacios GM, Schmidt C, Wichman T. Targeted therapy with phosphodiesterase 5 inhibitors in patients with pulmonary hypertension due to heart failure and elevated pulmonary vascular resistance: a systematic review. Pulm Circ 2020; 10:2045894020948780. [PMID: 33088478 PMCID: PMC7545768 DOI: 10.1177/2045894020948780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/18/2020] [Indexed: 12/31/2022] Open
Abstract
Pulmonary Hypertension due to left heart disease is the most common type of Pulmonary Hypertension. Morbidity and mortality significantly increase once Pulmonary Hypertension is present. Treatment is aimed toward optimizing the underlying condition. Targeted therapy has been evaluated in small studies with mixed results. The goal of this systematic review is to identify the possible benefit and safety of Phosphodiesterase 5 inhibitors in Pulmonary Hypertension due to left heart disease with elevated pulmonary vascular resistance, diagnosed by right heart catheterization. Electronic searches using MEDLINE/PREMEDLINE, EMBASE, and The Cochrane Library were searched on 21 October 2018. Randomized clinical trials comparing Phosphodiesterase 5 inhibitors versus placebo in patients with proven Pulmonary Hypertension by right heart catheterization secondary to left heart disease (both heart failure with reduced ejection fraction and with preserved ejection fraction) and reported pulmonary vascular resistance were included. We identified 436 potentially relevant studies. After reviewing the titles and abstracts to exclude irrelevant articles, five randomized clinical trials were considered for the study. Sildenafil was well tolerated among all studies. Sildenafil was found to improve hemodynamics, exercise capacity, and quality of life in patients with elevated pulmonary vascular resistance. Phosphodiesterase 5 inhibitors therapy in patients with proven Pulmonary Hypertension due to left heart disease and elevated pulmonary vascular resistance by right heart catheterization may improve the quality of life, exercise capacity, and pulmonary hemodynamics. Further prospective randomized controlled studies are needed to confirm.
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Affiliation(s)
| | - Cindy Schmidt
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Tammy Wichman
- University of Nebraska Medical Center, Omaha, NE, USA
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Raitière O, Berthelot E, Fauvel C, Guignant P, Si Belkacem N, Sitbon O, Bauer F. The dangerous and contradictory prognostic significance of PVR<3WU when TAPSE<16mm in postcapillary pulmonary hypertension. ESC Heart Fail 2020; 7:2398-2405. [PMID: 32705818 PMCID: PMC7524100 DOI: 10.1002/ehf2.12785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/26/2020] [Accepted: 05/04/2020] [Indexed: 11/10/2022] Open
Abstract
Aims In 2019, pulmonary vascular resistance (PVR) < 3WU was adopted to stratify patients at low risk in pulmonary hypertension due to left heart disease (PH‐LHD) as well those with isolated PH‐LHD. We sought to evaluate whether supervised machine learning with decision tree analysis, which provides more information than Cox Proportional analysis by forming a hierarchy of multiple covariates, confirms this risk stratification. Methods and results Two hundred two consecutive patients (mean age: 69 ± 11 years, female: 42%) with mean pulmonary artery pressure ≥ 20 mmHg and wedge pressure > 15 mmHg were recruited. Transpulmonary pressure gradient ⩾̸ 12 mmHg, PVR ⩾̸ 3WU, diastolic pressure gradient ⩾̸ 7 mmHg, pulmonary arterial capacitance < 1.1 mL/mmHg, tricuspid annular plane systolic excursion (TAPSE) < 16 mm, peak systolic tissue Doppler velocity < 10 cm/s, right ventricular end‐diastolic area ⩾̸ 25 cm2 were the seven categorical values entered into the model due to their prognostic significance in PH. We used the chi‐squared automatic interaction detection method to predict mortality. Each node and branch were compared using survival analysis at 6‐year follow‐up. Mean pulmonary artery pressure, wedge pressure, cardiac index, and PVR were 40.3 ± 10.0 mmHg, 22.3 ± 7.1 mmHg, 2.9 ± 0.8 L/min/m2, and 3.6 ± 2.1WU, respectively. Among the seven dichotomous, TAPSE was first selected following by PVR. Compared with patients with PVR < 3WU and TAPSE ⩾̸ 16 mm, patients with PVR ⩾̸ 3WU and TAPSE ⩾̸ 16 mm, or patients with PVR ⩾̸ 3WU and TAPSE<16 mm had significantly increased mortality, HR = 3.0, 95% CI = [1.4–6.4], P = 0.006 and HR = 3.3, 95% CI = [1.6–6.9], P = 0.002, respectively, while patients with PVR < 3WU and TAPSE < 16 mm exhibited the worst prognosis, HR = 7.2, 95% CI = [3.3–15.9], P = 0.0001. Conclusions Used for solving regression and classification problems, decision tree analysis confirms that PVR and TAPSE have to be analysed together in PH‐LHD and revealed the dangerous and contradictory prognostic significance of PVR < 3WU when TAPSE<16 mm.
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Affiliation(s)
- Olivier Raitière
- Department of Cardiac Surgery, Advanced Heart Failure Clinic and Pulmonary Hypertension Referral Center 27/76, Rouen University Hospital, Rouen, F76000, France.,Department of Cardiac Surgery, Normandie Univ, UNIROUEN, INSERM U1096, Rouen University Hospital, Rouen, F76000, France
| | - Emmanuelle Berthelot
- Department of Cardiology, APHP, Le Kremlin-Bicêtre University Hospital, Paris, 94276, France
| | - Charles Fauvel
- Department of Cardiac Surgery, Advanced Heart Failure Clinic and Pulmonary Hypertension Referral Center 27/76, Rouen University Hospital, Rouen, F76000, France
| | - Pierre Guignant
- Department of Cardiac Surgery, Advanced Heart Failure Clinic and Pulmonary Hypertension Referral Center 27/76, Rouen University Hospital, Rouen, F76000, France
| | - Nassima Si Belkacem
- Department of Cardiac Surgery, Advanced Heart Failure Clinic and Pulmonary Hypertension Referral Center 27/76, Rouen University Hospital, Rouen, F76000, France
| | - Olivier Sitbon
- Department of Cardiology, APHP, Le Kremlin-Bicêtre University Hospital, Paris, 94276, France.,INSERM UMR_S999, Université Paris-Sud, Hôpital Bicêtre, Le Kremlin-Bicêtre, 94270, France
| | - Fabrice Bauer
- Department of Cardiac Surgery, Advanced Heart Failure Clinic and Pulmonary Hypertension Referral Center 27/76, Rouen University Hospital, Rouen, F76000, France.,Department of Cardiac Surgery, Normandie Univ, UNIROUEN, INSERM U1096, Rouen University Hospital, Rouen, F76000, France
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30
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Al-Omary MS, Sugito S, Boyle AJ, Sverdlov AL, Collins NJ. Pulmonary Hypertension Due to Left Heart Disease. Hypertension 2020; 75:1397-1408. [DOI: 10.1161/hypertensionaha.119.14330] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Pulmonary hypertension (PH) due to left heart disease (LHD) is the most common type of PH and is defined as mean pulmonary artery systolic pressure of >20 mm Hg and pulmonary capillary wedge pressure >15 mm Hg during right heart catheterization. LHD may lead to elevated left atrial pressure alone, which in the absence of intrinsic pulmonary vascular disease will result in PH without changes in pulmonary vascular resistance. Persistent elevation in left atrial pressure may, however, also be associated with subsequent pulmonary vascular remodeling, vasoconstriction, and an increase in pulmonary vascular resistance. Hence, there are 2 subgroups of PH due to LHD, isolated postcapillary PH and combined post- and precapillary PH, with these groups have differing clinical implications. Differentiation of pulmonary arterial hypertension and PH due to LHD is critical to guide management planning; however, this may be challenging. Older patients, patients with metabolic syndrome, and patients with imaging and clinical features consistent with left ventricular dysfunction are suggestive of LHD etiology rather than pulmonary arterial hypertension. Hemodynamic measures such as diastolic pressure gradient, transpulmonary gradient, and pulmonary vascular resistance may assist to differentiate pre- from postcapillary PH and offer prognostic insights. However, these are influenced by fluid status and heart failure treatment. Pulmonary arterial hypertension therapies have been trialed in the treatment with concerning results reflecting disease heterogeneity, variation in inclusion criteria, and mixed end point criteria. The aim of this review is to provide an updated definition, discuss possible pathophysiology, clinical aspects, and the available treatment options for PH due to LHD.
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Affiliation(s)
- Mohammed S. Al-Omary
- From the Cardiovascular Department, John Hunter Hospital, Newcastle, Australia (M.S.A., S.S., A.J.B., A.L.S., N.J.C.)
- School of Medicine and Public Health, University of Newcastle, Australia (M.S.A., A.J.B., A.L.S., N.J.C.)
| | - Stuart Sugito
- From the Cardiovascular Department, John Hunter Hospital, Newcastle, Australia (M.S.A., S.S., A.J.B., A.L.S., N.J.C.)
| | - Andrew J. Boyle
- From the Cardiovascular Department, John Hunter Hospital, Newcastle, Australia (M.S.A., S.S., A.J.B., A.L.S., N.J.C.)
- School of Medicine and Public Health, University of Newcastle, Australia (M.S.A., A.J.B., A.L.S., N.J.C.)
| | - Aaron L. Sverdlov
- From the Cardiovascular Department, John Hunter Hospital, Newcastle, Australia (M.S.A., S.S., A.J.B., A.L.S., N.J.C.)
- School of Medicine and Public Health, University of Newcastle, Australia (M.S.A., A.J.B., A.L.S., N.J.C.)
| | - Nicholas J. Collins
- From the Cardiovascular Department, John Hunter Hospital, Newcastle, Australia (M.S.A., S.S., A.J.B., A.L.S., N.J.C.)
- School of Medicine and Public Health, University of Newcastle, Australia (M.S.A., A.J.B., A.L.S., N.J.C.)
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31
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Manouras A, Johnson J, Lund LH, Nagy AI. Optimizing diastolic pressure gradient assessment. Clin Res Cardiol 2020; 109:1411-1422. [PMID: 32394159 PMCID: PMC7588394 DOI: 10.1007/s00392-020-01641-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 03/31/2020] [Indexed: 12/25/2022]
Abstract
Aims The diastolic pressure gradient (DPG) has been proposed as a marker pulmonary vascular disease in the setting of left heart failure (HF). However, its diagnostic utility is compromised by the high prevalence of physiologically incompatible negative values (DPGNEG) and the contradictory evidence on its prognostic value. Pressure pulsatility impacts on DPG measurements, thus conceivably, pulmonary artery wedge pressure (PAWP) measurements insusceptible to the oscillatory effect of the V-wave might yield a more reliable DPG assessment. We set out to investigate how the instantaneous PAWP at the trough of the Y-descent (PAWPY) influences the prevalence of DPGNEG and the prognostic value of the resultant DPGY. Methods Hundred and fifty-three consecutive HF patients referred for right heart catheterisation were enrolled prospectively. DPG, as currently recommended, was calculated. Subsequently, PAWPY was measured and the corresponding DPGY was calculated. Results DPGY yielded higher values (median, IQR: 3.2, 0.6–5.7 mmHg) than DPG (median, IQR: 0.9, − 1.7–3.8 mmHg); p < 0.001. Conventional DPG was negative in 45% of the patients whereas DPGY in only 15%. During follow-up (22 ± 14 months) 58 patients have undergone heart-transplantation or died. The predictive ability of DPGY ≥ 6 mmHg for the above defined end-point events was significant [HR 2.1; p = 0.007] and independent of resting mean pulmonary artery pressure (PAPM). In contrast, conventional DPG did not comprise significant prognostic value following adjustment for PAPM. Conclusion Instantaneous pressures at the trough of Y-descent yield significantly fewer DPGNEG than conventional DPG and entail superior prognostic value in HF patients with and without PH. Graphic abstract ![]()
Electronic supplementary material The online version of this article (10.1007/s00392-020-01641-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aristomenis Manouras
- Department of Medicine, Karolinska Institute, Solna, Stockholm, Sweden.,Theme of Heart and Vessels, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Johnson
- Centre for Fetal Medicine Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - Lars H Lund
- Department of Medicine, Karolinska Institute, Solna, Stockholm, Sweden.,Theme of Heart and Vessels, Karolinska University Hospital, Stockholm, Sweden
| | - Anikó Ilona Nagy
- Department of Medicine, Karolinska Institute, Solna, Stockholm, Sweden. .,Heart and Vascular Center, Semmelweis University, 68. Városmajor u., Budapest, 1026, Hungary.
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32
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Rosenkranz S, Kramer T, Gerhardt F, Opitz C, Olsson KM, Hoeper MM. Pulmonary hypertension in HFpEF and HFrEF: Pathophysiology, diagnosis, treatment approaches. Herz 2019; 44:483-490. [PMID: 31317203 DOI: 10.1007/s00059-019-4831-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pulmonary hypertension (PH) is a frequent hemodynamic condition that is highly prevalent in patients with heart failure and reduced (HFrEF) or preserved ejection fraction (HFpEF). Irrespective of left ventricular EF, the presence of PH and right ventricular (RV) dysfunction are highly relevant for morbidity and mortality in patients with heart failure. While elevated left-sided filling pressures and functional mitral regurgitation primarily lead to post-capillary PH, current guidelines and recommendations distinguish between isolated post-capillary PH (IpcPH) and combined post- and pre-capillary PH (CpcPH), the latter being defined by a pulmonary vascular resistance (PVR) of ≥3 Wood units. Here, we describe the pathophysiology and clinical relevance of these distinct entities, and report on the diagnostic work-up including remote pulmonary artery pressure (PAP) monitoring. Furthermore, we highlight strategies to manage PH and improve RV function in heart failure, which may include optimized management of HFrEF and HFpEF (medical and interventional), sufficient volume control, catheter-based mitral valve repair, and-in selected cases-targeted PH therapy. In this context, we also highlight gaps in evidence and the need for further research.
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Affiliation(s)
- S Rosenkranz
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum der Universität zu Köln, Kerpener Str. 62, 50937, Cologne, Germany.
| | - T Kramer
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum der Universität zu Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - F Gerhardt
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum der Universität zu Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - C Opitz
- Klinik für Innere Medizin, Schwerpunkt Kardiologie, DRK-Kliniken Berlin, Berlin, Germany
| | - K M Olsson
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - M M Hoeper
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
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33
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Tichelbäcker T, Dumitrescu D, Gerhardt F, Stern D, Wissmüller M, Adam M, Schmidt T, Frerker C, Pfister R, Halbach M, Baldus S, Rosenkranz S. Pulmonary hypertension and valvular heart disease. Herz 2019; 44:491-501. [PMID: 31312873 DOI: 10.1007/s00059-019-4823-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Pulmonary hypertension (PH) is an important contributor to morbidity and mortality in patients with left-sided heart disease, including valvular heart disease. In this context, elevated left atrial pressure primarily leads to the development of post-capillary PH. Despite the fact that repair of left-sided valvular heart disease by surgical or interventional approaches will improve PH, recent studies have highlighted that PH (pre- or post-interventional) remains an important predictor of long-term outcome. Here, we review the current knowledge on PH in valvular heart disease taking into account new hemodynamic PH definitions, and the distinction between post- and pre-capillary components of PH. A specific focus is on the precise characterization of hemodynamics and cardiopulmonary interaction, and on potential strategies for the management of residual PH after mitral or aortic valve interventions. In addition, we highlight the clinical significance of tricuspid regurgitation, which may occur as a primary condition or as a consequence of PH and right heart dilatation (functional). In this context, proper patient selection for potential tricuspid valve interventions is crucial. Finally, the article highlights gaps in evidence, and points toward future perspectives.
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Affiliation(s)
- T Tichelbäcker
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - D Dumitrescu
- Klinik für Allgemeine und Interventionelle Kardiologie, Herz- und Diabeteszentrum NRW, Bad Oeynhausen, Germany
| | - F Gerhardt
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - D Stern
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - M Wissmüller
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - M Adam
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - T Schmidt
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - C Frerker
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - R Pfister
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - M Halbach
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - S Baldus
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - S Rosenkranz
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany.
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Abstract
In early 2019, the 6th World Symposium on Pulmonary Hypertension (WSPH) released an updated document highlighting the advances in the last five years. During the quinquennial event many experts worked together to suggest new changes in the disease diagnosis and management. Since inception of the WSPH in 1973, this is the first time when the hemodynamic definition of pulmonary hypertension (PH) has been updated. These proceedings have re-defined the different hemodynamic types of PH that occur with the left heart disease along with introduction to the genetic testing as part of pulmonary arterial hypertension (PAH) evaluation. Objective of this review is to highlight the evaluation and diagnosis of PAH based on the proceedings of the 6th WSPH. Accurate early diagnosis and subsequent management of PH is necessary, as despite of treatment advances, survival remains suboptimal.
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Affiliation(s)
- Sandeep Sahay
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, Institute of Academic Medicine, Houston Methodist Hospital, Houston, TX, USA
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35
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Condon DF, Nickel NP, Anderson R, Mirza S, de Jesus Perez VA. The 6th World Symposium on Pulmonary Hypertension: what's old is new. F1000Res 2019; 8. [PMID: 31249672 PMCID: PMC6584967 DOI: 10.12688/f1000research.18811.1] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2019] [Indexed: 12/24/2022] Open
Abstract
In February 2018, the 6th World Symposium on Pulmonary Hypertension (WSPH) brought together experts from various disciplines to review the most relevant clinical and scientific advances in the field of PH over the last 5 years. Based on careful review and discussions by members of the different task forces, major revisions were made on the hemodynamic definition for various forms of PH and new genes were added to the list of genetic markers associated with pulmonary arterial hypertension (PAH) and pulmonary veno-occlusive disease. In addition, the use of risk stratification tools was encouraged as a strategy to reduce one-year mortality risk in PAH patients through early implementation of PAH therapies. While members of the medical community are still debating some of the proposed changes, the new WSPH guidelines advocate early diagnosis and initiation of combination therapy to reduce mortality and improve quality of life in patients with PH.
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Affiliation(s)
- David F Condon
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, USA
| | - Nils P Nickel
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, USA
| | - Ryan Anderson
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, USA
| | - Shireen Mirza
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, USA.,Vera Moulton Wall Center for Pulmonary Vascular Research, Stanford University, Stanford, USA
| | - Vinicio A de Jesus Perez
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, USA.,Vera Moulton Wall Center for Pulmonary Vascular Research, Stanford University, Stanford, USA
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36
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Vachiéry JL, Tedford RJ, Rosenkranz S, Palazzini M, Lang I, Guazzi M, Coghlan G, Chazova I, De Marco T. Pulmonary hypertension due to left heart disease. Eur Respir J 2019; 53:13993003.01897-2018. [PMID: 30545974 PMCID: PMC6351334 DOI: 10.1183/13993003.01897-2018] [Citation(s) in RCA: 342] [Impact Index Per Article: 68.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/07/2018] [Indexed: 12/22/2022]
Abstract
Pulmonary hypertension (PH) is frequent in left heart disease (LHD), as a consequence of the underlying condition. Significant advances have occurred over the past 5 years since the 5th World Symposium on Pulmonary Hypertension in 2013, leading to a better understanding of PH-LHD, challenges and gaps in evidence. PH in heart failure with preserved ejection fraction represents the most complex situation, as it may be misdiagnosed with group 1 PH. Based on the latest evidence, we propose a new haemodynamic definition for PH due to LHD and a three-step pragmatic approach to differential diagnosis. This includes the identification of a specific “left heart” phenotype and a non-invasive probability of PH-LHD. Invasive confirmation of PH-LHD is based on the accurate measurement of pulmonary arterial wedge pressure and, in patients with high probability, provocative testing to clarify the diagnosis. Finally, recent clinical trials did not demonstrate a benefit in treating PH due to LHD with pulmonary arterial hypertension-approved therapies. State of the art and research perspectives in pulmonary hypertension due to left heart disease including diagnostic and treatment insightshttp://ow.ly/vr0I30md6KC
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Affiliation(s)
- Jean-Luc Vachiéry
- Dept of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Ryan J Tedford
- Division of Cardiology, Dept of Medicine, Medical University of South Carolina (MUSC), Charleston, SC, USA
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine, Dept of Cardiology, Heart Center at the University of Cologne and Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
| | | | - Irene Lang
- Dept of Cardiology, AKH-Vienna, Medical University of Vienna, Vienna, Austria
| | - Marco Guazzi
- Dept of Biomedical Sciences for Health, University of Milan and Dept of Cardiology University, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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Pulmonary hypertension associated with left heart disease: Updated Recommendations of the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:53-62. [PMID: 30527996 DOI: 10.1016/j.ijcard.2018.08.080] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 12/25/2022]
Abstract
In the summer of 2016, delegates from the German Society of Cardiology (DGK), the German Respiratory Society (DGP), and the German Society of Pediatric Cardiology (DGPK) met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary hypertension (PH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines, aiming at their practical implementation, considering country-specific issues, and including new evidence, where available. To this end, a number of working groups was initiated, one of which was specifically dedicated to PH associated with left heart disease. In this context, the European Guidelines point out that the drugs currently approved to treat patients with PAH (prostanoids, endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, sGC stimulators) have not sufficiently been investigated in other forms of PH. However, despite the lack of respective efficacy data, an uncritical use of targeted PAH drugs in patients with PH associated with left heart disease is currently observed at an increasing rate. This development is a matter of concern. On the other hand, PH is a frequent problem that is highly relevant for morbidity and mortality in patients with left heart disease. In that sense, the distinction between isolated post-capillary pulmonary hypertension (IpcPH) and combined post- and pre-capillary pulmonary hypertension (CpcPH) and their proper definition may be of particular relevance. The detailed results and recommendations of the working group on PH associated with left heart disease, which were last updated in the spring of 2018, are summarized in this article.
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