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Watabe K, Goda A, Tobita K, Yokoyama S, Kikuchi H, Takeuchi K, Inami T, Soejima K, Kohno T. Determinants of physical quality of life in patients with chronic thromboembolic pulmonary hypertension after treatment: Insights from invasive exercise stress test. J Heart Lung Transplant 2024:S1053-2498(24)01562-6. [PMID: 38636934 DOI: 10.1016/j.healun.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Impaired quality of life (QoL) is prevalent among patients with chronic thromboembolic pulmonary hypertension (CTEPH) despite improved survival due to medical advances. We clarified the physical QoL of patients with CTEPH with mildly elevated pulmonary hemodynamics and evaluated its determinants using a database of patients with CTEPH evaluated for hemodynamics during exercise. METHODS The QoL was measured in 144 patients with CTEPH (age, 66 (58-73) years; men/women, 48/96) with mildly elevated mean pulmonary artery pressure (<30 mm Hg) at rest after treatment with balloon pulmonary angioplasty and/or pulmonary endarterectomy using the Short-Form 36 (SF-36) questionnaire. The enrolled patients were divided into 2 groups: physical component summary (PCS) scores in the SF-36 over 50 as PCS-good and those under 50 as PCS-poor. RESULTS The median PCS in SF-36 score was 43.4 (IQR 32.4-49.5) points. The PCS-poor group (n = 110) was older and had lower exercise capacity and SaO2 during exercise. PCS scores were correlated with 6-minute walk distance (rs=0.40, p < 0.001), quadriceps strength (rs=0.34, p < 0.001), peak VO2 (rs=0.31, p < 0.001), SaO2 at rest (rs=0.35, p < 0.001) and peak exercise (rs=0.33, p < 0.001), home oxygen therapy usage (rs=-0.28, p = 0.001), and pulmonary vascular resistance at peak exercise (rs=-0.26, p = 0.002). CONCLUSIONS The impairment of physical QoL was common in patients with CTEPH with improved hemodynamics; exercise capacity, hypoxemia, and hemodynamic status during exercise were related to the physical QoL.
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Affiliation(s)
- Kosuke Watabe
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan.
| | - Kazuki Tobita
- Department of Rehabilitation, Kyorin University Hospital, Tokyo, Japan
| | - Sachi Yokoyama
- Department of Rehabilitation, Kyorin University Hospital, Tokyo, Japan; Nursing Department, Yumino Heart Clinic, Tokyo, Japan
| | - Hanako Kikuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Kaori Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Takumi Inami
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
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Panagiotidou E, Βoutou A, Fouka E, Papakosta D, Chatzopoulos E, Sourla E, Markopoulou A, Kioumis I, Stanopoulos I, Pitsiou G. Phenotyping exercise limitation of patients with Interstitial Fibrosing Lung Disease: the importance of exercise hemodynamics. Pulmonology 2024; 30:104-112. [PMID: 35568651 DOI: 10.1016/j.pulmoe.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION AND OBJECTIVE Left-heart dysfunction and pulmonary vasculopathy are increasingly recognized as contributing factors of exercise capacity limitation in interstitial fibrosing lung disease (IFLD). Moreover, the clinical significance of exercise pulmonary hypertension (ePH) in pulmonary and cardiac diseases has been documented, representing a risk factor for decreased exercise capacity and survival, progression to resting pulmonary hypertension (PH) and overall clinical worsening. We conducted a prospective study aiming at: (a) assessing the prevalence of PH and ePH in a cohort of 40 functionally limited patients with IFLD, (b) determining the post-capillary (postC) or pre-capillary (preC) etiology of either PH or ePH in this cohort, and (c) examining the correlations between invasively and non-invasively measured exercise variables among hemodynamic groups. PATIENTS AND METHODS 40 IFLD patients underwent cardiopulmonary evaluation, including: clinical examination, lung function tests, 6-minute walking test, heart ultrasonography, cardiopulmonary exercise test and, finally, right heart catheterization (RHC). Resting hemodynamic evaluation was followed by the exercise protocol proposed by Herve et al, using a bedside cycle ergometer in the supine position. Abnormal elevation of mean pulmonary artery pressure (mPAP) above 30mmHg during exercise, with respect to abnormal elevation of cardiac output (CO) below 10 L/min (mPAP-CO ratio ⩾3 mmHg·min·L-1) was used to define ePH (Herve et al, 2015). Secondary hemodynamic evaluation involved detection of abnormal pulmonary arterial wedge pressure (PAWP) increase at peak exercise in relation to CO. Specifically, ΔPAWP/ΔCO >2 mmHg/L per minute determined an abnormal PAWP elevation (Bentley et al, 2020). RESULTS Among the 40-patient cohort, 25% presented postC PH, 37.5% preC PH, 27.5% ePH, with the remaining 10% recording normal hemodynamics. PAWP evaluation during exercise revealed a postC etiology in 4 out of the 11 patients presenting ePH, and a postC etiology in 6 out of the 15 patients presenting resting preC PH. Mean values of non-invasive variables did not display statistically significant differences among hemodynamic groups, except for: diffusing capacity for carbon monoxide (DLCO), carbon monoxide transfer coefficient (KCO) and the ratio of functional vital capacity to DLCO (FVC%/DLCO%), which were lower in both ePH and PH groups (p < 0.05). Resting values of CO, cardiac index (CI), stroke volume (SV) and pulmonary vascular compliance (PVC) were significantly impaired in ePH, preC-PH and postC-PH groups when compared to the normal group. CONCLUSIONS Both PH and ePH were highly prevalent within the IFLD patient group, suggesting that RHC should be offered more frequently in functionally limited patients. Diffusion capacity markers must thus guide decision making, in parallel to clinical evaluation. ePH was associated to lower resting CO and PVC, in a similar way to resting PH, indicating the relevance of cardiopulmonary function to exercise limitation. Finally, the use of the ΔPAWP/ΔCO>2 criterion further uncovered PH of postcapillary etiology, highlighting the complexity of hemodynamics in IFLD. CLINICALTRIALS gov ID: NCT03706820.
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Affiliation(s)
- E Panagiotidou
- Respiratory Failure Clinic, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - A Βoutou
- Department of Respiratory Medicine, General Hospital "G. Papanikolaou", Thessaloniki, Greece
| | - E Fouka
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - D Papakosta
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - E Chatzopoulos
- Respiratory Failure Clinic, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - E Sourla
- Respiratory Failure Clinic, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - A Markopoulou
- Department of Respiratory Medicine, General Hospital "G. Papanikolaou", Thessaloniki, Greece
| | - I Kioumis
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - I Stanopoulos
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - G Pitsiou
- University Department of Respiratory Medicine, General Hospital of Thessaloniki "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
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Huertas Nieto S, Velázquez Martín M, Sarnago Cebada F, Jiménez López-Guarch C, Maneiro Melón N, Flox Camacho Á, Segura de la Cal T, Cruz Utrilla A, Aguilar Colindres R, López Gude MJ, Quezada Loaiza CA, Revilla Ostolaza Y, Alonso Charterina S, Gómez Cuervo C, Arribas Ynsaurriaga F, Escribano Subías P. Value of exercise right heart catheterization in the differential diagnosis of chronic thromboembolic pulmonary disease. Rev Esp Cardiol (Engl Ed) 2024; 77:158-166. [PMID: 37863183 DOI: 10.1016/j.rec.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 06/16/2023] [Indexed: 10/22/2023]
Abstract
INTRODUCTION AND OBJECTIVES Chronic thromboembolic disease refers to the presence of chronic thrombotic pulmonary vascular thrombosis without pulmonary hypertension (PH) at rest but with exercise limitation after pulmonary embolism (PE). Our aim was to evaluate the hemodynamic response to exercise in these patients and its correlation with the values reached in cardiopulmonary exercise testing. METHODS We included symptomatic patients with persistent pulmonary thrombosis after PE. We excluded patients with left heart disease or significant PH (mean pulmonary arterial pressure [mPAP] >25mmHg, pulmonary vascular resistance >3 WU, and pulmonary capillary wedge pressure [PCWP] >15mmHg). Cardiopulmonary exercise testing and exercise right heart catheterization were performed. Exercise-induced precapillary PH was defined as mPAP/CO slope >3 and PCWP/CO slope <2mmHg/l/min. The hemodynamic response and the values obtained in cardiopulmonary exercise testing were compared between patients with and without exercise-induced precapillary PH. RESULTS We studied 36 patients; 4 were excluded due to incomplete hemodynamic data. Out of the 32 patients analyzed; 3 developed a pathological increase in PCWP. Among the remaining 29 patients (mean age, 49.4±13.7 years, 34.5% women), 13 showed exercise-induced PH. Resting mPAP was higher in those who developed exercise-induced PH (23.3±5.4 vs 19.0±3.8mmHg; P=.012), although CO was similar in the 2 groups. Patients with exercise-induced PH exhibited data of ventilatory inefficiency with reduced values of end-tidal CO2 pressure at the anaerobic threshold (32.8±3.0 vs 36.2±3.3mmHg; P=.021) and a higher Ve/VCO2 slope (34.2±4.8 vs 30.7±5.0; P=.049). CONCLUSIONS Exercise limitation and ventilatory inefficiency could be attributable to exercise-induced precapillary PH in a subgroup of patients with persistent pulmonary thrombosis and dyspnea.
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Affiliation(s)
- Sergio Huertas Nieto
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Unidad de Hemodinámica, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain.
| | - Maite Velázquez Martín
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Unidad de Hemodinámica, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Fernando Sarnago Cebada
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Unidad de Hemodinámica, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Carmen Jiménez López-Guarch
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Nicolás Maneiro Melón
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Unidad de Hemodinámica, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Ángela Flox Camacho
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Teresa Segura de la Cal
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Alejandro Cruz Utrilla
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | | | - María Jesús López Gude
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Carlos Andrés Quezada Loaiza
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain; Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Spain
| | - Yolanda Revilla Ostolaza
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Servicio de Radiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Sergio Alonso Charterina
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Servicio de Radiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Fernando Arribas Ynsaurriaga
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Unidad de Hemodinámica, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Pilar Escribano Subías
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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Kirupaharan P, Lane J, Melillo C, Paul D, Amoushref A, Abdi SA, Tonelli AR. Impact of body position on hemodynamic measurements during exercise: A tale of two bikes. Pulm Circ 2024; 14:e12334. [PMID: 38223421 PMCID: PMC10784616 DOI: 10.1002/pul2.12334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/06/2023] [Accepted: 12/22/2023] [Indexed: 01/16/2024] Open
Abstract
The addition of exercise testing during right heart catheterization (RHC) is often required to accurately diagnose causes of exercise intolerance like early pulmonary vascular disease, occult left heart disease, and preload insufficiency. We tested the influence of body position (supine vs. seated) on hemodynamic classification both at rest and during exercise. We enrolled patients with exercise intolerance due to dyspnea who were referred for exercise RHC at the Cleveland Clinic. Patients were randomized (1:1) to exercise in seated or supine position to a goal of 60 W followed by maximal exercise in the alternate position. We analyzed 17 patients aged 60.3 ± 10.9 years, including 13 females. At rest in the sitting position, patients had significantly lower right atrial pressure (RAP), mean pulmonary artery pressure (mPAP), pulmonary artery wedge pressure (PAWP) and cardiac index (CI). In every stage of exercise (20, 40, and 60 W), the RAP, mPAP, and PAWP were lower in the sitting position. Exercise in the sitting position allowed the identification of preload insufficiency in nine patients. Exercise in either position increased the identification of postcapillary pulmonary hypertension (PH). Body position significantly influences hemodynamics at rest and with exercise; however, mPAP/CO and PAWP/CO were not positionally affected. Hemodynamic measurements in the seated position allowed the detection of preload insufficiency, a condition that was predominantly identified as no PH during supine exercise.
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Affiliation(s)
- Pradhab Kirupaharan
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory InstituteCleveland ClinicClevelandOhioUSA
| | - James Lane
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory InstituteCleveland ClinicClevelandOhioUSA
| | - Celia Melillo
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory InstituteCleveland ClinicClevelandOhioUSA
| | - Deborah Paul
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory InstituteCleveland ClinicClevelandOhioUSA
| | - Alla Amoushref
- Department of Nephrology, Glickman Urological & Kidney InstituteCleveland ClinicClevelandOhioUSA
| | - Sami Al Abdi
- Department of Internal MedicineCleveland Clinic Fairview HospitalFairviewOhioUSA
| | - Adriano R. Tonelli
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory InstituteCleveland ClinicClevelandOhioUSA
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Baratto C, Caravita S, Vachiéry JL. Pulmonary Hypertension Associated with Left Heart Disease. Semin Respir Crit Care Med 2023; 44:810-825. [PMID: 37709283 DOI: 10.1055/s-0043-1772754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Pulmonary hypertension (PH) is a common complication of diseases affecting the left heart, mostly found in patients suffering from heart failure, with or without preserved left ventricular ejection fraction. Initially driven by a passive increase in left atrial pressure (postcapillary PH), several mechanisms may lead in a subset of patient to significant structural changes of the pulmonary vessels or a precapillary component. In addition, the right ventricle may be independently affected, which results in right ventricular to pulmonary artery uncoupling and right ventricular failure, all being associated with a worse outcome. The differential diagnosis of PH associated with left heart disease versus pulmonary arterial hypertension (PAH) is especially challenging in patients with cardiovascular comorbidities and/or heart failure with preserved ejection fraction (HFpEF). A stepwise approach to diagnosis is proposed, starting with a proper clinical multidimensional phenotyping to identify patients in whom hemodynamic confirmation is deemed necessary. Provocative testing (exercise testing, fluid loading, or simple leg raising) is useful in the cath laboratory to identify patients with abnormal response who are more likely to suffer from HFpEF. In contrast with group 1 PH, management of PH associated with left heart disease must focus on the treatment of the underlying condition. Some PAH-approved targets have been unsuccessfully tried in clinical studies in a heterogeneous group of patients, some even leading to an increase in adverse events. There is currently no approved therapy for PH associated with left heart disease.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Bergamo, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, HUB Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
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Bordag N, Nagy BM, Zügner E, Ludwig H, Foris V, Nagaraj C, Biasin V, Bodenhofer U, Magnes C, Maron BA, Ulrich S, Lange TJ, Hötzenecker K, Pieber T, Olschewski H, Olschewski A. Lipidomics for diagnosis and prognosis of pulmonary hypertension. medRxiv 2023:2023.05.17.23289772. [PMID: 37292870 PMCID: PMC10246148 DOI: 10.1101/2023.05.17.23289772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background Pulmonary hypertension (PH) poses a significant health threat with high morbidity and mortality, necessitating improved diagnostic tools for enhanced management. Current biomarkers for PH lack functionality and comprehensive diagnostic and prognostic capabilities. Therefore, there is a critical need to develop biomarkers that address these gaps in PH diagnostics and prognosis. Methods To address this need, we employed a comprehensive metabolomics analysis in 233 blood based samples coupled with machine learning analysis. For functional insights, human pulmonary arteries (PA) of idiopathic pulmonary arterial hypertension (PAH) lungs were investigated and the effect of extrinsic FFAs on human PA endothelial and smooth muscle cells was tested in vitro. Results PA of idiopathic PAH lungs showed lipid accumulation and altered expression of lipid homeostasis-related genes. In PA smooth muscle cells, extrinsic FFAs caused excessive proliferation and endothelial barrier dysfunction in PA endothelial cells, both hallmarks of PAH.In the training cohort of 74 PH patients, 30 disease controls without PH, and 65 healthy controls, diagnostic and prognostic markers were identified and subsequently validated in an independent cohort. Exploratory analysis showed a highly impacted metabolome in PH patients and machine learning confirmed a high diagnostic potential. Fully explainable specific free fatty acid (FFA)/lipid-ratios were derived, providing exceptional diagnostic accuracy with an area under the curve (AUC) of 0.89 in the training and 0.90 in the validation cohort, outperforming machine learning results. These ratios were also prognostic and complemented established clinical prognostic PAH scores (FPHR4p and COMPERA2.0), significantly increasing their hazard ratios (HR) from 2.5 and 3.4 to 4.2 and 6.1, respectively. Conclusion In conclusion, our research confirms the significance of lipidomic alterations in PH, introducing innovative diagnostic and prognostic biomarkers. These findings may have the potential to reshape PH management strategies.
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Affiliation(s)
- Natalie Bordag
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- CBmed GmbH, Center for Biomarker Research in Medicine, Graz, Austria
- BioMedTech, Graz, Austria
| | - Bence Miklos Nagy
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Elmar Zügner
- Institute for Biomedical Research and Technologies (HEALTH), Joanneum Research Forschungsgesellschaft m.b.H, Graz, Austria
| | - Helga Ludwig
- School of Informatics, Communications, and Media, University of Applied Sciences Upper Austria, Hagenberg, Austria
| | - Vasile Foris
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Chandran Nagaraj
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- BioMedTech, Graz, Austria
| | - Valentina Biasin
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Physiology, Otto Loewi Research Centre, Medical University of Graz, Graz, Austria
| | - Ulrich Bodenhofer
- School of Informatics, Communications, and Media, University of Applied Sciences Upper Austria, Hagenberg, Austria
| | - Christoph Magnes
- Institute for Biomedical Research and Technologies (HEALTH), Joanneum Research Forschungsgesellschaft m.b.H, Graz, Austria
| | - Bradley A. Maron
- University of Maryland School of Medicine, Baltimore, MD and The University of Maryland-Institute for Health Computing, Bethesda, MD, USA
| | - Silvia Ulrich
- Clinic of Pulmonology, University and University Hospital of Zurich, Zürich, Switzerland
| | - Tobias J. Lange
- Department of Internal Medicine II, Pulmonology and Critical Care, Kreisklinik Bad Reichenhall, Bad Reichenhall, Germany
- Faculty of Medicine, University of Regensburg, Regensburg, Germany
| | - Konrad Hötzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Pieber
- CBmed GmbH, Center for Biomarker Research in Medicine, Graz, Austria
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz Austria
- BioMedTech, Graz, Austria
| | - Horst Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioMedTech, Graz, Austria
| | - Andrea Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Experimental Anaesthesiology, Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
- BioMedTech, Graz, Austria
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Gargani L, Pugliese NR, De Biase N, Mazzola M, Agoston G, Arcopinto M, Argiento P, Armstrong WF, Bandera F, Cademartiri F, Carbone A, Castaldo R, Citro R, Cocchia R, Codullo V, D'Alto M, D'Andrea A, Douschan P, Fabiani I, Ferrara F, Franzese M, Frumento P, Ghio S, Grünig E, Guazzi M, Kasprzak JD, Kolias T, Kovacs G, La Gerche A, Limogelli G, Marra AM, Matucci-Cerinic M, Mauro C, Moreo A, Pratali L, Ranieri B, Rega S, Rudski L, Saggar R, Salzano A, Serra W, Stanziola AA, Vannan MA, Voilliot D, Vriz O, Wierzbowska-Drabik K, Cittadini A, Naeije R, Bossone E. Exercise Stress Echocardiography of the Right Ventricle and Pulmonary Circulation. J Am Coll Cardiol 2023; 82:1973-1985. [PMID: 37968015 DOI: 10.1016/j.jacc.2023.09.807] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/25/2023] [Accepted: 09/05/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Exercise echocardiography is used for assessment of pulmonary circulation and right ventricular function, but limits of normal and disease-specific changes remain insufficiently established. OBJECTIVES The objective of this study was to explore the physiological vs pathologic response of the right ventricle and pulmonary circulation to exercise. METHODS A total of 2,228 subjects were enrolled: 375 healthy controls, 40 athletes, 516 patients with cardiovascular risk factors, 17 with pulmonary arterial hypertension, 872 with connective tissue diseases without overt pulmonary hypertension, 113 with left-sided heart disease, 30 with lung disease, and 265 with chronic exposure to high altitude. All subjects underwent resting and exercise echocardiography on a semirecumbent cycle ergometer. All-cause mortality was recorded at follow-up. RESULTS The 5th and 95th percentile of the mean pulmonary artery pressure-cardiac output relationships were 0.2 to 3.5 mm Hg.min/L in healthy subjects without cardiovascular risk factors, and were increased in all patient categories and in high altitude residents. The 5th and 95th percentile of the tricuspid annular plane systolic excursion to systolic pulmonary artery pressure ratio at rest were 0.7 to 2.0 mm/mm Hg at rest and 0.5 to 1.5 mm/mm Hg at peak exercise, and were decreased at rest and exercise in all disease categories and in high-altitude residents. An increased all-cause mortality was predicted by a resting tricuspid annular plane systolic excursion to systolic pulmonary artery pressure <0.7 mm/mm Hg and mean pulmonary artery pressure-cardiac output >5 mm Hg.min/L. CONCLUSIONS Exercise echocardiography of the pulmonary circulation and the right ventricle discloses prognostically relevant differences between healthy subjects, athletes, high-altitude residents, and patients with various cardio-respiratory conditions. (Right Heart International NETwork During Exercise in Different Clinical Conditions; NCT03041337).
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Affiliation(s)
- Luna Gargani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | | | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Matteo Mazzola
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Gergely Agoston
- Institute of Family Medicine, University of Szeged, Szeged, Hungary
| | - Michele Arcopinto
- Department of Translational Medical Sciences, University of Naples "Federico II," Naples, Italy
| | - Paola Argiento
- Department of Cardiology, Monaldi Hospital - University "L. Vanvitelli," Naples, Italy
| | - William F Armstrong
- Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Francesco Bandera
- Heart Failure and Rehabilitation Cardiology Unit, IRCCS MultiMedica, Sesto San Giovanni, Milano, Italy; Department of Biomedical Sciences for Health, University of Milano, Milano, Italy
| | | | - Andreina Carbone
- Department of Cardiology, Monaldi Hospital - University "L. Vanvitelli," Naples, Italy
| | | | - Rodolfo Citro
- Cardio-Thoracic-Vascular Department, University Hospital "San Giovanni Di Dio E Ruggi D'Aragona," Salerno, Italy; Department of Vascular Pathophysiology, IRCCS Neuromed, Pozzilli, Isernia, Italy
| | | | - Veronica Codullo
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Michele D'Alto
- Department of Cardiology, Monaldi Hospital - University "L. Vanvitelli," Naples, Italy
| | - Antonello D'Andrea
- Department of Cardiology, Umberto I Hospital Nocera Inferiore, Nocera Inferiore, Italy
| | | | - Iacopo Fabiani
- Department of Imaging, Fondazione Monasterio/CNR, Pisa, Italy
| | - Francesco Ferrara
- Cardio-Thoracic-Vascular Department, University Hospital "San Giovanni Di Dio E Ruggi D'Aragona," Salerno, Italy
| | | | - Paolo Frumento
- Department of Political Sciences, University of Pisa, Pisa, Italy
| | - Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Ekkehard Grünig
- Center of Pulmonary Hypertension, Thoraxklinik Heidelberg at Heidelberg University Hospital, Heidelberg, Germany
| | - Marco Guazzi
- University of Milano School of Medicine, Department of Biological Sciences, Milano, Italy; San Paolo Hospital, Cardiology Division, Milano, Italy
| | - Jaroslaw D Kasprzak
- Department of Cardiology, Bieganski Hospital, Medical University of Lodz, Lodz, Poland
| | - Theodore Kolias
- Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Gabor Kovacs
- Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - André La Gerche
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, Fitzroy, Vicotria, Australia
| | - Giuseppe Limogelli
- Department of Cardiology, Monaldi Hospital - University "L. Vanvitelli," Naples, Italy
| | - Alberto Maria Marra
- Department of Translational Medical Sciences, University of Naples "Federico II," Naples, Italy
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology AOUC, Florence, Italy; Unit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), IRCCS San Raffaele Hospital, Milan, Italy
| | - Ciro Mauro
- Cardiology Division, "A. Cardarelli" Hospital, Naples, Italy
| | - Antonella Moreo
- A. De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Lorenza Pratali
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | | | - Salvatore Rega
- Department of Public Health, University of Naples "Federico II," Naples, Italy
| | - Lawrence Rudski
- Azrieli Heart Center and Center for Pulmonary Vascular Diseases, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Rajan Saggar
- Lung & Heart-Lung Transplant and Pulmonary Hypertension Programs, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | | | - Walter Serra
- Cardiology Division, University Hospital, Parma, Italy
| | - Anna A Stanziola
- Department of Respiratory Diseases, Monaldi Hospital, University "Federico II," Naples, Italy
| | - Mani A Vannan
- Piedmont Heart Institute, Marcus Heart Valve Center, Atlanta, Georgia, USA
| | - Damien Voilliot
- Centre Hospitalier Lunéville, Service de Cardiologie, Lunéville, France
| | - Olga Vriz
- Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Karina Wierzbowska-Drabik
- Department of Internal Diseases and Clinical Pharmacology, Bieganski Hospital, Medical University of Lodz, Lodz, Poland
| | - Antonio Cittadini
- Department of Translational Medical Sciences, University of Naples "Federico II," Naples, Italy
| | | | - Eduardo Bossone
- Institute of Clinical Physiology, National Research Council, Pisa, Italy.
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8
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Tello K, Richter MJ, Kremer N, Gall H, Egenlauf B, Sorichter S, Heberling M, Douschan P, Hager A, Yogeswaran A, Behr J, Xanthouli P, Held M. [Diagnostic Algorithm and Screening of Pulmonary Hypertension]. Pneumologie 2023; 77:871-889. [PMID: 37963477 DOI: 10.1055/a-2145-4678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
The new guidelines for the diagnosis and treatment of pulmonary hypertension include a new diagnostic algorithm and provide specific recommendations for the required diagnostic procedures, including screening methods. These recommendations are commented on by national experts under the auspices of the DACH. These comments provide additional decision support and background information, serving as a further guide for the complex diagnosis of pulmonary hypertension.
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Affiliation(s)
- Khodr Tello
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Manuel J Richter
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Nils Kremer
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Henning Gall
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Benjamin Egenlauf
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland, Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Stephan Sorichter
- Klinik für Pneumologie und Beatmungsmedizin, St.-Josefskrankenhaus, Freiburg im Breisgau, Deutschland
| | - Melanie Heberling
- Universitätsklinikum Dresden, Med. Klinik I, Pneumologie, Dresden, Deutschland
| | - Philipp Douschan
- Abteilung für Pulmonologie, Universitätsklinik für Innere Medizin, Graz, Österreich; Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Österreich
| | - Alfred Hager
- Department of Paediatric Cardiology and Congenital Heart Defects, Deutsches Herzzentrum München, München, Deutschland
| | - Athiththan Yogeswaran
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Jürgen Behr
- LMU Klinikum München, Medizinische Klinik und Poliklinik V, München, Deutschland. Comprehensive Pneumology Center (CPC-M), Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Panagiota Xanthouli
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland, Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Matthias Held
- Klinikum Würzburg Mitte, Medizinische Klinik Schwerpunkt Pneumologie & Beatmungsmedizin, Würzburg, Deutschland
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Douschan P, Egenlauf B, Gall H, Grünig E, Hager A, Heberling M, Koehler T, Olschewski H, Seyfarth HJ, Yogeswaran A, Ulrich S, Kovacs G. [New definition and classification of pulmonary hypertension]. Pneumologie 2023; 77:854-861. [PMID: 37963475 DOI: 10.1055/a-2145-4648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
In the recent ESC/ERS guidelines on the diagnosis and management of pulmonary hypertension (PH) several important changes have been made in respect of the definition and classification of PH.The mPAP cut-off for defining PH was lowered. PH is now defined by an mPAP > 20 mmHg assessed by right heart catheterization. Moreover, the PVR threshold for defining precapillary PH was lowered. Precapillary PH is now defined by a PVR > 2 WU and a pulmonary arterial wedge pressure (PAWP) ≤ 15 mmHg. Furthermore, the increasing evidence for the clinical relevance of pulmonary exercise hemodynamics led to the reintroduction of exercise pulmonary hypertension (EPH) 1. EPH is characterized by a mPAP/CO-slope > 3 mmHg/L/min during exercise testing. In the classification of PH five groups are distinguished: Pulmonary arterial hypertension (group 1), PH associated with left heart disease (group 2), PH associated with lung diseases and/or hypoxia (Group 3), PH associated with pulmonary artery obstructions (group 4) and PH with unclear and/or multi-factorial mechanisms (group 5).In the following guideline-translation we focus on novel aspects regarding the definition and classification of PH and to provide additional background information.
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Affiliation(s)
- Philipp Douschan
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Benjamin Egenlauf
- Zentrum für Pulmonale Hypertonie, Thoraxklinik am Universitätsklinikum Heidelberg, Heidelberg, Germany
- Abteilung für Pneumologie und Beatmungsmedizin, Thoraxklinik am Universitätsklinikum Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Henning Gall
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Ekkehard Grünig
- Zentrum für Pulmonale Hypertonie, Thoraxklinik am Universitätsklinikum Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Alfred Hager
- Department for Congenital Heart Disease and Paediatric Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Melanie Heberling
- Universitätsklinikum Carl Gustav Carus an der TU Dresden, Med. Klinik I, Bereich Pneumologie, Dresden, Deutschland
| | - Thomas Koehler
- Universitätsklinikum Freiburg, Department Innere Medizin, Klinik für Pneumologie, Freiburg, Deutschland
| | - Horst Olschewski
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Hans-Jürgen Seyfarth
- Department of Pneumology, Medical Clinic II, University Hospital of Leipzig, Leipzig, Germany
| | - Athiththan Yogeswaran
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Silvia Ulrich
- Klinik für Pneumologie, Universitätsspital Zürich, Zürich, Schweiz
| | - Gabor Kovacs
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
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10
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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Shen CP, Bagsic SRS, Pandey AC. Strain and Exercise-Induced Pulmonary Hypertension. Am J Cardiol 2023; 205:442-444. [PMID: 37666015 DOI: 10.1016/j.amjcard.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/03/2023] [Indexed: 09/06/2023]
Affiliation(s)
| | | | - Amitabh C Pandey
- Division of Cardiology, Scripps Clinic, San Diego, California; Scripps Research Translational Institute, Scripps Research, San Diego, California; Section of Cardiology, Tulane University Heart and Vascular Institute, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana; Southeast Louisiana Veterans Healthcare System, New Orleans, Louisiana.
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12
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Goda A, Takeuchi K, Kikuchi H, Inami T, Kohno T, Soejima K, Satoh T. Pulmonary artery pressure-perfusion relation during exercise in patients with chronic thromboembolic pulmonary hypertension using pulmonary arteriography and right-heart catheterization. Int J Cardiol Heart Vasc 2023; 48:101252. [PMID: 37663616 PMCID: PMC10474603 DOI: 10.1016/j.ijcha.2023.101252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/19/2023] [Accepted: 07/28/2023] [Indexed: 09/05/2023]
Abstract
Background In pulmonary hypertension (PH), pulmonary artery pressure (PAP) does not increase to pulmonary perfusion (PP) < 50%. During exercise, PAP may be increased even at PP > 50% for the early detection of PP disorders. The relationship between PP estimated by pulmonary angiography (PAG) and PAP was evaluated in patients with chronic thromboembolic PH (CTEPH) treated by balloon pulmonary angioplasty with near-normal PH. Methods Thirty-one patients (age 60 ± 11 years) with CTEPH underwent catheterization at rest and during exercise. Each segmental PP was determined by visualization of its segmental pulmonary artery and graded from 0 to 3 in the PAG. PP was estimated as the percentage PAG (%PAG) score-%summed total of all segmental PP/the full score-54. Results The mean PAP (mPAP) increased from 28 ± 6 mmHg to 46 ± 10 mmHg during exercise. Transpulmonary pressure gradient, the value of mPAP with the pulmonary artery wedge pressure substituted at peak exercise, was negatively correlated with %PAG score (rs = -0.56, p < 0.001) and elevated at > 50% PP. Conclusions The PAP-PP relationship at peak exercise was correlated, shifting from the relationship at rest, and the PAP started to rise with PP > 50%.
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Affiliation(s)
- Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University, Tokyo, Japan
| | - Kaori Takeuchi
- Department of Cardiovascular Medicine, Kyorin University, Tokyo, Japan
| | - Hanako Kikuchi
- Department of Cardiovascular Medicine, Kyorin University, Tokyo, Japan
| | - Takumi Inami
- Department of Cardiovascular Medicine, Kyorin University, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University, Tokyo, Japan
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University, Tokyo, Japan
| | - Toru Satoh
- Department of Cardiovascular Medicine, Kyorin University, Tokyo, Japan
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Rischard FP, Bernardo RJ, Vanderpool RR, Kwon DH, Acharya T, Park MM, Katrynuik A, Insel M, Kubba S, Badagliacca R, Larive AB, Naeije R, Garcia JG, Beck GJ, Erzurum SC, Frantz RP, Hassoun PM, Hemnes AR, Hill NS, Horn EM, Leopold JA, Rosenzweig EB, Wilson Tang W, Wilcox JD. Classification and Predictors of Right Ventricular Functional Recovery in Pulmonary Arterial Hypertension. Circ Heart Fail 2023; 16:e010555. [PMID: 37664964 PMCID: PMC10592283 DOI: 10.1161/circheartfailure.123.010555] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 07/17/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Normative changes in right ventricular (RV) structure and function have not been characterized in the context of treatment-associated functional recovery (RV functional recovery [RVFnRec]). The aim of this study is to assess the clinical relevance of a proposed RVFnRec definition. METHODS We evaluated 63 incident patients with pulmonary arterial hypertension by right heart catheterization and cardiac magnetic resonance imaging at diagnosis and cardiac magnetic resonance imaging and invasive cardiopulmonary exercise testing following treatment (≈11 months). Sex, age, ethnicity matched healthy control subjects (n=62) with 1-time cardiac magnetic resonance imaging and noninvasive cardiopulmonary exercise testing were recruited from the PVDOMICS (Redefining Pulmonary Hypertension through Pulmonary Vascular Disease Phenomics) project. We examined therapeutic cardiac magnetic resonance imaging changes relative to the evidence-based peak oxygen consumption (VO2peak)>15 mL/(kg·min) to define RVFnRec by receiver operating curve analysis. Afterload was measured as mean pulmonary artery pressure, resistance, compliance, and elastance. RESULTS A drop in RV end-diastolic volume of -15 mL best defined RVFnRec (area under the curve, 0.87; P=0.0001) and neared upper 95% CI RV end-diastolic volume of controls. This cutoff was met by 22 out of 63 (35%) patients which was reinforced by freedom from clinical worsening, RVFnRec 1 out of 21 (5%) versus no RVFnRec 17 out of 42, 40% (log-rank P=0.006). A therapy-associated increase of 0.8 mL/mm Hg in compliance had the best predictive value of RVFnRec (area under the curve, 0.76; [95% CI, 0.64-0.88]; P=0.001). RVFnRec patients had greater increases in stroke volume, and cardiac output at exercise. CONCLUSIONS RVFnRec defined by RV end-diastolic volume therapeutic decrease of -15 mL predicts exercise capacity, freedom from clinical worsening, and nears normalization. A therapeutic improvement of compliance is superior to other measures of afterload in predicting RVFnRec. RVFnRec is also associated with increased RV output reserve at exercise.
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Affiliation(s)
- Franz P. Rischard
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Arizona
| | - Roberto J. Bernardo
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | | | | | - Tushar Acharya
- Divison of Cardiology, University of Arizona, Tucson, AZ
| | | | | | - Michael Insel
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Arizona
| | - Saad Kubba
- Divison of Cardiology, University of Arizona, Tucson, AZ
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, Rome, Italy
| | - A Brett Larive
- Department of Quantitative Health Sciences, Cleveland Clinic
| | - Robert Naeije
- Department of Pathophysiology, Free University of Brussels, Brussels, Belgium
| | | | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic
| | | | | | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center
| | - Evelyn M Horn
- Perkin Heart Failure Center, Division of Cardiology, Weill Cornell Medicine
| | - Jane A Leopold
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - Erika B. Rosenzweig
- Department of Pediatrics and Medicine, Columbia University, Vegelos College of Physicians and Surgeons
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14
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Kularatne M, Boucly A, Savale L, Solinas S, Cheron C, Roche A, Jevnikar M, Jaïs X, Montani D, Humbert M, Sitbon O. Pharmacological management of connective tissue disease-associated pulmonary arterial hypertension. Expert Opin Pharmacother 2023; 24:2101-2115. [PMID: 37869785 DOI: 10.1080/14656566.2023.2273395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/17/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is a severe, progressive pulmonary vasculopathy (Group 1 Pulmonary Hypertension (PH)) that complicates the course of many connective tissue diseases (CTD). Detailed testing is required to differentiate PAH from other types of PH caused by CTD such as left heart disease (Group 2 PH), pulmonary parenchymal disease (Group 3 PH), and chronic thromboembolic pulmonary hypertension (Group 4 PH). PAH is most frequently seen in systemic sclerosis but can also be seen with systemic lupus erythematosus, mixed CTD, and primary Sjogren's syndrome. AREAS COVERED This review discusses the epidemiology of CTD-associated PAH, outlines the complex diagnosis approach, and finishes with an in-depth discussion on the current treatment paradigm. Focus is placed on challenges faced in the treatment of CTD-associated PAH, (decreased efficacy and poorer tolerance of pharmacological therapies) and includes a discussion on the future investigational treatments. EXPERT OPINION Despite significant advances over the past decades with more aggressive treatment algorithms, CTD-associated PAH patients continue to have poorer survival compared to those with idiopathic PAH. This review highlights factors leading to disparate outcomes compared to other forms of PAH, and discusses on further improvements that may increase quality of life and survival for CTD-associated PAH patients.
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Affiliation(s)
- Mithum Kularatne
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Calgary, Canada
| | - Athénaïs Boucly
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Laurent Savale
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Sabina Solinas
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Céline Cheron
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Anne Roche
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Mitja Jevnikar
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Xavier Jaïs
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - David Montani
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- AP-HP, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Centre, DMU 5 Thorinno, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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15
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Baratto C, Caravita S, Dewachter C, Faini A, Perego GB, Bondue A, Senni M, Muraru D, Badano LP, Parati G, Vachiéry JL. Right Heart Adaptation to Exercise in Pulmonary Hypertension: An Invasive Hemodynamic Study. J Card Fail 2023; 29:1261-1272. [PMID: 37150503 DOI: 10.1016/j.cardfail.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 04/12/2023] [Accepted: 04/12/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Right heart failure (RHF) is associated with a dismal prognosis in patients with pulmonary hypertension (PH). Exercise right heart catheterization may unmask right heart maladaptation as a sign of RHF. We sought to (1) define the normal limits of right atrial pressure (RAP) increase during exercise; (2) describe the right heart adaptation to exercise in PH owing to heart failure with preserved ejection fraction (PH-HFpEF) and in pulmonary arterial hypertension (PAH); and (3) identify the factors associated with right heart maladaptation during exercise. METHODS AND RESULTS We analyzed rest and exercise right heart catheterization from patients with PH-HFpEF and PAH. Right heart adaptation was described by absolute or cardiac output (CO)-normalized changes of RAP during exercise. Individuals with noncardiac dyspnea (NCD) served to define abnormal RAP responses (>97.5th percentile). Thirty patients with PH-HFpEF, 30 patients with PAH, and 21 patients with NCD were included. PH-HFpEF were older than PAH, with more cardiovascular comorbidities, and a higher prevalence of severe tricuspid regurgitation (P < .05). The upper limit of normal for peak RAP and RAP/CO slope in NCD were >12 mm Hg and ≥1.30 mm Hg/L/min, respectively. PH-HFpEF had higher peak RAP and RAP/CO slope than PAH (20 mm Hg [16-24 mm Hg] vs 12 mm Hg [9-19 mm Hg] and 3.47 mm Hg/L/min [2.02-6.19 mm Hg/L/min] vs 1.90 mm Hg/L/min [1.01-4.29 mm Hg/L/min], P < .05). A higher proportion of PH-HFpEF had RAP/CO slope and peak RAP above normal (P < .001). Estimated stressed blood volume at peak exercise was higher in PH-HFpEF than PAH (P < .05). In the whole PH cohort, the RAP/CO slope was associated with age, the rate of increase in estimated stressed blood volume during exercise, severe tricuspid regurgitation, and right atrial dilation. CONCLUSIONS Patients with PH-HFpEF display a steeper increase of RAP during exercise than those with PAH. Preload-mediated mechanisms may play a role in the development of exercise-induced RHF.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy.
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Andrea Faini
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano, Italy
| | | | - Antoine Bondue
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Michele Senni
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Jean-Luc Vachiéry
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy
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16
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Johnson S, Sommer N, Cox-Flaherty K, Weissmann N, Ventetuolo CE, Maron BA. Pulmonary Hypertension: A Contemporary Review. Am J Respir Crit Care Med 2023; 208:528-548. [PMID: 37450768 PMCID: PMC10492255 DOI: 10.1164/rccm.202302-0327so] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/14/2023] [Indexed: 07/18/2023] Open
Abstract
Major advances in pulmonary arterial hypertension, pulmonary hypertension (PH) associated with lung disease, and chronic thromboembolic PH cast new light on the pathogenetic mechanisms, epidemiology, diagnostic approach, and therapeutic armamentarium for pulmonary vascular disease. Here, we summarize key basic, translational, and clinical PH reports, emphasizing findings that build on current state-of-the-art research. This review includes cutting-edge progress in translational pulmonary vascular biology, with a guide to the diagnosis of patients in clinical practice, incorporating recent PH definition revisions that continue emphasis on early detection of disease. PH management is reviewed including an overview of the evolving considerations for the approach to treatment of PH in patients with cardiopulmonary comorbidities, as well as a discussion of the groundbreaking sotatercept data for the treatment of pulmonary arterial hypertension.
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Affiliation(s)
- Shelsey Johnson
- The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical Care, Boston University School of Medicine, Boston, Massachusetts
- Department of Pulmonary and Critical Care Medicine and
| | - Natascha Sommer
- Excellence Cluster Cardiopulmonary Institute, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | | | - Norbert Weissmann
- Excellence Cluster Cardiopulmonary Institute, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | - Corey E. Ventetuolo
- Department of Medicine and
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island
| | - Bradley A. Maron
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
- Department of Cardiology and Department of Pulmonary, Allergy, Sleep, and Critical Care Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland; and
- The University of Maryland-Institute for Health Computing, Bethesda, Maryland
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17
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Müller J, Mayer L, Schneider SR, Titz A, Schwarz EI, Saxer S, Furian M, Grünig E, Ulrich S, Lichtblau M. Pulmonary arterial wedge pressure increase during exercise in patients diagnosed with pulmonary arterial or chronic thromboembolic pulmonary hypertension. ERJ Open Res 2023; 9:00379-2023. [PMID: 37753275 PMCID: PMC10518874 DOI: 10.1183/23120541.00379-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/02/2023] [Indexed: 09/28/2023] Open
Abstract
Background The course of pulmonary arterial wedge pressure (PAWP) during exercise in patients with pulmonary arterial or chronic thromboembolic pulmonary hypertension (PAH/CTEPH), further abbreviated as pulmonary vascular disease (PVD), is still unknown. The aim of the study was to describe PAWP during exercise in patients with PVD. Methods In this cross-sectional study, right heart catheter (RHC) data including PAWP, recorded during semi-supine, stepwise cycle exercise in patients with PVD, were analysed retrospectively. We investigated PAWP changes during exercise until end-exercise. Results In 121 patients (59 female, 66 CTEPH, 55 PAH, 62±17 years) resting PAWP was 10.2±4.1 mmHg. Corresponding peak changes in PAWP during exercise were +2.9 mmHg (95% CI 2.1-3.7 mmHg, p<0.001). Patients ≥50 years had a significantly higher increase in PAWP during exercise compared with those <50 years (p<0.001). The PAWP/cardiac output (CO) slopes were 3.9 WU for all patients, and 1.6 WU for patients <50 years and 4.5 WU for those ≥50 years. Conclusion In patients with PVD, PAWP increased slightly but significantly with the onset of exercise compared to resting values. The increase in PAWP during exercise was age-dependent, with patients ≥50 years showing a rapid PAWP increase even with minimal exercise. PAWP/CO slopes >2 WU are common in patients with PVD aged ≥50 years without exceeding the PAWP of 25 mmHg during exercise.
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Affiliation(s)
- Julian Müller
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Laura Mayer
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Simon R. Schneider
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Anna Titz
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Esther I. Schwarz
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Stephanie Saxer
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Michael Furian
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | | | - Silvia Ulrich
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- These authors contributed equally
| | - Mona Lichtblau
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- These authors contributed equally
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18
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Boucly A, Gerges C, Savale L, Jaïs X, Jevnikar M, Montani D, Sitbon O, Humbert M. Pulmonary arterial hypertension. Presse Med 2023; 52:104168. [PMID: 37516248 DOI: 10.1016/j.lpm.2023.104168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/17/2023] [Indexed: 07/31/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare and progressive disease characterised by remodelling of the pulmonary arteries and progressive narrowing of the pulmonary vasculature. This leads to a progressive increase in pulmonary vascular resistance and pulmonary arterial pressure and, if left untreated, to right ventricular failure and death. A correct diagnosis requires a complete work-up including right heart catheterisation performed in a specialised centre. Although our knowledge of the epidemiology, pathology and pathophysiology of the disease, as well as the development of innovative therapies, has progressed in recent decades, PAH remains a serious clinical condition. Current treatments for the disease target the three specific pathways of endothelial dysfunction that characterise PAH: the endothelin, nitric oxide and prostacyclin pathways. The current treatment algorithm is based on the assessment of severity using a multiparametric risk stratification approach at the time of diagnosis (baseline) and at regular follow-up visits. It recommends the initiation of combination therapy in PAH patients without cardiopulmonary comorbidities. The choice of therapy (dual or triple) depends on the initial severity of the condition. The main treatment goal is to achieve low-risk status. Further escalation of treatment is required if low-risk status is not achieved at subsequent follow-up assessments. In the most severe patients, who are already on maximal medical therapy, lung transplantation may be indicated. Recent advances in understanding the pathophysiology of the disease have led to the development of promising emerging therapies targeting dysfunctional pathways beyond endothelial dysfunction, including the TGF-β and PDGF pathways.
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Affiliation(s)
- Athénaïs Boucly
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France; National Heart and Lung Institute, Imperial College London, London, UK.
| | - Christian Gerges
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Laurent Savale
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Xavier Jaïs
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Mitja Jevnikar
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - David Montani
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
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19
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Baratto C, Faini A, Gallone GP, Dewachter C, Perego GB, Bondue A, Muraru D, Senni M, Badano LP, Parati G, Vachiéry JL, Caravita S. Pulmonary artery wedge pressure and left ventricular end-diastolic pressure during exercise in patients with dyspnoea. ERJ Open Res 2023; 9:00750-2022. [PMID: 37670852 PMCID: PMC10475984 DOI: 10.1183/23120541.00750-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/29/2023] [Indexed: 03/18/2023] Open
Abstract
Background Pulmonary artery wedge pressure (PAWP) during exercise, as a surrogate for left ventricular (LV) end-diastolic pressure (EDP), is used to diagnose heart failure with preserved ejection fraction (HFpEF). However, LVEDP is the gold standard to assess LV filling, end-diastolic PAWP (PAWPED) is supposed to coincide with LVEDP and mean PAWP throughout the cardiac cycle (PAWPM) better reflects the haemodynamic load imposed on the pulmonary circulation. The objective of the present study was to determine precision and accuracy of PAWP estimates for LVEDP during exercise, as well as the rate of agreement between these measures. Methods 46 individuals underwent simultaneous right and left heart catheterisation, at rest and during exercise, to confirm/exclude HFpEF. We evaluated: linear regression between LVEDP and PAWP, Bland-Altman graphs, and the rate of concordance of dichotomised LVEDP and PAWP ≥ or < diagnostic thresholds for HFpEF. Results At peak exercise, PAWPM and LVEDP, as well as PAWPED and LVEDP, were fairly correlated (R2>0.69, p<0.01), with minimal bias (+2 and 0 mmHg respectively) but large limits of agreement (±11 mmHg). 89% of individuals had concordant PAWP and LVEDP ≥ or <25 mmHg (Cohen's κ=0.64). Individuals with either LVEDP or PAWPM ≥25 mmHg showed a PAWPM increase relative to cardiac output (CO) changes (PAWPM/CO slope) >2 mmHg·L-1·min-1. Conclusions During exercise, PAWP is accurate but not precise for the estimation of LVEDP. Despite a good rate of concordance, these two measures might occasionally disagree.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
| | - Andrea Faini
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Gianluca P. Gallone
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium
| | - Giovanni B. Perego
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
| | - Antoine Bondue
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michele Senni
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Luigi P. Badano
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
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20
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Dharmavaram N, Esmaeeli A, Jacobson K, Brailovsky Y, Raza F. Cardiopulmonary Exercise Testing, Rehabilitation, and Exercise Training in Postpulmonary Embolism. Interv Cardiol Clin 2023; 12:349-365. [PMID: 37290839 DOI: 10.1016/j.iccl.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Long-term exercise intolerance and functional limitations are common after an episode of acute pulmonary embolism (PE), despite 3 to 6 months of anticoagulation. These persistent symptoms are reported in more than half of the patients with acute PE and are referred as "post-PE syndrome." Although these functional limitations can occur from persistent pulmonary vascular occlusion or pulmonary vascular remodeling, significant deconditioning can be a major contributing factor. Herein, the authors review the role of exercise testing to elucidate the mechanisms of exercise limitations to guide next steps in management and exercise training for musculoskeletal deconditioning.
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Affiliation(s)
- Naga Dharmavaram
- Division of Cardiology, Department of Medicine, University of Wisconsin-Madison, Hospitals and Clinics, 600 Highland Avenue CSC-E5/582B, Madison, WI 53792, USA
| | - Amir Esmaeeli
- Division of Cardiology, Department of Medicine, University of Wisconsin-Madison, Hospitals and Clinics, 600 Highland Avenue CSC-E5/582B, Madison, WI 53792, USA
| | - Kurt Jacobson
- Division of Cardiology, Department of Medicine, University of Wisconsin-Madison, Hospitals and Clinics, 600 Highland Avenue CSC-E5/582B, Madison, WI 53792, USA
| | - Yevgeniy Brailovsky
- Division of Cardiology, Department of Medicine, Jefferson Heart Institute-Sidney Kimmel School of Medicine, Thomas Jefferson University, 111 South 11th Street, Philadelphia, PA 19107, USA
| | - Farhan Raza
- Division of Cardiology, Department of Medicine, University of Wisconsin-Madison, Hospitals and Clinics, 600 Highland Avenue CSC-E5/582B, Madison, WI 53792, USA.
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21
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Škafar M, Ambrožič J, Toplišek J, Cvijić M. Role of Exercise Stress Echocardiography in Pulmonary Hypertension. Life (Basel) 2023; 13:1385. [PMID: 37374168 PMCID: PMC10302645 DOI: 10.3390/life13061385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/31/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
Resting and exercise right heart catheterisation is the gold standard method to diagnose and differentiate types of pulmonary hypertension (PH). As it carries technical challenges, the question arises if non-invasive exercise stress echocardiography may be used as an alternative. Exercise echocardiography can unmask exercise PH, detect the early stages of left ventricular diastolic dysfunction, and, therefore, differentiate between pre- and post-capillary PH. Regardless of the underlying aetiology, a developed PH is associated with increased mortality. Parameters of overt right ventricle (RV) dysfunction, including RV dilation, reduced RV ejection fraction, and elevated right-sided filling pressures, are detectable with resting echocardiography and are associated with worse outcome. However, these measures all fail to identify occult RV dysfunction. Echocardiographic measures of RV contractile reserve during exercise echocardiography are very promising and provide incremental prognostic information on clinical outcome. In this paper, we review pulmonary haemodynamic response to exercise, briefly describe the modalities for assessing pulmonary haemodynamics, and discuss in depth the contemporary key clinical application of exercise stress echocardiography in patients with PH.
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Affiliation(s)
- Mojca Škafar
- Department of Cardiology, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia; (M.Š.); (J.A.); (J.T.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
| | - Jana Ambrožič
- Department of Cardiology, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia; (M.Š.); (J.A.); (J.T.)
| | - Janez Toplišek
- Department of Cardiology, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia; (M.Š.); (J.A.); (J.T.)
| | - Marta Cvijić
- Department of Cardiology, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia; (M.Š.); (J.A.); (J.T.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
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22
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Ge J, Ye Y, Tan Y, Liu F, Jiang Y, Lu J. High-frequency chest wall oscillation multiple times daily can better reduce the loss of pulmonary surfactant and improve lung compliance in mechanically ventilated patients. Heart Lung 2023; 61:114-119. [PMID: 37247538 DOI: 10.1016/j.hrtlng.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/10/2023] [Accepted: 05/16/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND High-frequency chest wall oscillation (HFCWO) has been widely recognized for its airway secretion clearance effectiveness in critically ill ICU patients. OBJECTIVES The purpose of this randomized controlled trial is to validate and compare the effects of different frequencies of HFCWO on oxygenation, lung compliance, and pulmonary surfactant proteins (SPs) in critically ill patients admitted to the intensive care unit (ICU). METHODS Sixty patients with severe craniocerebral injury treated with a tracheostomy and mechanical ventilation were randomized into three groups (20 patients in each group): a single group (treated with 30 minutes of HFCWO once daily) and a double group (treated with 30 minutes of HFCWO twice daily), and a blank group (treated without HFCWO). Primary outcome measures included results on several specific proteins (SP-A, SP-B, SP-C, and SP-D) in serum and alveolar lavage fluid. Secondary outcome measures were lung static compliance test and oxygenation. RESULTS Patients in both the single and double groups exhibited significant oxygenation and static compliance improvement. Similar results were observed in changes in SPs concentrations in the alveolar lavage fluid. However, a significant reduction of SPs levels was observed in the serum. In the group comparison analysis for the same variables between the single and double group, twice daily HFCWO treatments showed a significantly better result. CONCLUSION Compared with HFCWO once daily, HFCWO twice daily is advantageous in patients with tracheostomy and prolonged ventilation, which demonstrated significantly greater effectiveness in improving oxygenation and lung static compliance linked to the increase of and SPs contents in the airways as well as a reduction of SPs shift from airways to the blood.
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Affiliation(s)
- Jiaqi Ge
- Department of Critical Care Medicine, The Affiliated Yixing Hospital of Jiangsu University, Wuxi, Jiangsu, PR China; Jiangsu University, Zhenjiang, Jiangsu, PR China.
| | - Yinjie Ye
- Department of Critical Care Medicine, The Affiliated Yixing Hospital of Jiangsu University, Wuxi, Jiangsu, PR China.
| | - Yongfei Tan
- Cardiothoracic intensive care unit, The Affiliated Yixing Hospital of Jiangsu University, Wuxi, Jiangsu, PR China; Cardiac-Thoracic Surgery, The Affiliated Yixing Hospital of Jiangsu University, Wuxi, Jiangsu, PR China.
| | - Fang Liu
- Department of Critical Care Medicine, The Affiliated Yixing Hospital of Jiangsu University, Wuxi, Jiangsu, PR China.
| | - Yan Jiang
- Department of Critical Care Medicine, The Affiliated Yixing Hospital of Jiangsu University, Wuxi, Jiangsu, PR China.
| | - Junjie Lu
- Department of Critical Care Medicine, The Affiliated Yixing Hospital of Jiangsu University, Wuxi, Jiangsu, PR China.
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23
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Guo W, Zhang M, Li H, Wang Y, Zhang W, Chen Y, Duan S, Guo X, Yin A, Peng J, An C, Xiao Y, Wan J. A comparative study on the diagnostic efficacy of different diagnostic criteria for exercise pulmonary hypertension. Int J Cardiol 2023; 381:94-100. [PMID: 37019218 DOI: 10.1016/j.ijcard.2023.03.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/20/2023] [Accepted: 03/31/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Exercise pulmonary hypertension (ePH) has three common diagnostic criteria: the mean pulmonary artery pressure (mPAP) > 30 mmHg and total pulmonary resistance (TPR) at peak exercise >3 Wood units ("Joint criteria"), the mPAP/cardiac output (CO) slope of the two-point measurement (ΔmPAP/ΔCO) > 3 mmHg/L/min ("Two-point criteria"), and the mPAP/CO slope of the multi-point data >3 mmHg/L/min ("Multi-point criteria"). We compared the diagnostic efficacy of these criteria, which remain controversial. METHODS Following resting right heart catheterization (RHC), all patients underwent exercise RHC (eRHC). The patients were divided into different ePH and non-exercise pulmonary hypertension (nPH) groups according to the above criteria. Joint criteria were used as the reference to compare the other two, namely diagnostic concordance, sensitivity and specificity. We conducted further analysis to determine the correlation between different diagnostic criteria grouping and the clinical severity of PH. RESULTS Thirty-three patients with mPAPrest ≤ 20 mmHg were enrolled. a) Diagnostic concordance, sensitivity and specificity: compared with Joint criteria, the diagnostic concordances of Two-point criteria and Multi-point criteria were 78.8% (κ = 0.570, P < 0.01) and 90.9% (κ = 0.818, P < 0.01), respectively; the sensitivity of Two-point criteria was high (100%), but the specificity was poor (56.3%); however, Multi-point criteria exhibited higher sensitivity (94.1%) and specificity (87.5%). b) Clinically relevant analysis: a significant difference was observed in several clinical severity indicators between ePH and nPH patients according to Multi-point criteria grouping(all P < 0.05). CONCLUSION Multi-point criteria are more clinically relevant and provide better diagnostic efficiency.
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Affiliation(s)
- Wei Guo
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Meng Zhang
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Hui Li
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Yan Wang
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Wenmei Zhang
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Yong Chen
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Shengchen Duan
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Xueran Guo
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Ao Yin
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Jiafei Peng
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Chunrong An
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Yao Xiao
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China
| | - Jun Wan
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University; Beijing Institute of Heart, Lung and Blood Vessel Diseases; Beijing 100029, China.
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24
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Saito Y, Obokata M, Harada T, Kagami K, Murata M, Sorimachi H, Kato T, Wada N, Okumura Y, Ishii H. Diagnostic value of expired gas analysis in heart failure with preserved ejection fraction. Sci Rep 2023; 13:4355. [PMID: 36928614 PMCID: PMC10020480 DOI: 10.1038/s41598-023-31381-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 03/10/2023] [Indexed: 03/18/2023] Open
Abstract
Cardiopulmonary exercise testing (CPET) may potentially differentiate heart failure (HF) with preserved ejection fraction (HFpEF) from noncardiac causes of dyspnea (NCD). While contemporary guidelines for HF recommend using CPET for identifying causes of unexplained dyspnea, data supporting this practice are limited. This study aimed to determine the diagnostic value of expired gas analysis to distinguish HFpEF from NCD. Exercise stress echocardiography with simultaneous expired gas analysis was performed in patients with HFpEF (n = 116) and those with NCD (n = 112). Participants without dyspnea symptoms were also enrolled as controls (n = 26). Exercise capacity was impaired in patients with HFpEF than in controls and those with NCD, evidenced by lower oxygen consumption (VO2), but there was a substantial overlap between HFpEF and NCD. Receiver operating characteristic curve analyses showed modest diagnostic abilities of expired gas analysis data in differentiating individuals with HFpEF from the controls; however, none of these variables clearly differentiated between HFpEF and NCD (all areas under the curve < 0.61). Expired gas analysis provided objective assessments of exercise capacity; however, its diagnostic value in identifying HFpEF among patients with symptoms of exertional dyspnea was modest.
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Affiliation(s)
- Yuki Saito
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan.
| | - Tomonari Harada
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Kazuki Kagami
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
- Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Makoto Murata
- Department of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Gunma, Japan
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Toshimitsu Kato
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Naoki Wada
- Department of Rehabilitation Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | | | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
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Rischard FP, Bernardo RJ, Vanderpool RR, Kwon DH, Acharya T, Park MM, Katrynuik A, Insel M, Kubba S, Badagliacca R, Larive AB, Naeije R, Garcia JGN, Beck GJ, Erzurum SC, Frantz RP, Hassoun PM, Hemnes AR, Hill NS, Horn EM, Leopold JA, Rosenzweig EB, Tang WHW, Wilcox JD. Classification and Predictors of Right Ventricular Functional Recovery in Pulmonary Arterial Hypertension. medRxiv 2023:2023.02.15.23285974. [PMID: 36824981 PMCID: PMC9949192 DOI: 10.1101/2023.02.15.23285974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Background Normative changes in right ventricular (RV) structure and function have not been characterized in the context of treatment-associated functional recovery (RVFnRec). The aim of this study is to assess the clinical relevance of a proposed RVFnRec definition. Methods We evaluated 63 incident patients with PAH by right heart catheterization and cardiac MRI (CMR) at diagnosis and CMR and invasive cardiopulmonary exercise (CPET) following treatment (∼11 months). Sex, age, race/ethnicity matched healthy control subjects (n=62) with one-time CMR and non-invasive CPET were recruited from the PVDOMICS project. We examined therapeutic CMR changes relative to the evidence-based peak oxygen consumption (VO2 peak )>15mL/kg/min to define RVFnRec by receiver operating curve analysis. Afterload was measured in the as mean pulmonary artery pressure, resistance, compliance, and elastance. Results A drop in RV end-diastolic volume of -15 mL best defined RVFnRec (AUC 0.87, P=0.0001) and neared upper 95% CI RVEDV of controls. 22/63 (35%) of subjects met this cutoff which was reinforced by freedom from clinical worsening, RVFnRec 1/21 (5%) versus no RVFnRec 17/42, 40%, (log rank P=0.006). A therapy-associated increase of 0.8 mL/mmHg in compliance had the best predictive value of RVFnRec (AUC 0.76, CI 0.64-0.88, P=0.001). RVFnRec subjects had greater increases in stroke volume, and cardiac output at exercise. Conclusions RVFnRec defined by RVEDV therapeutic decrease of -15mL predicts exercise capacity, freedom from clinical worsening, and nears normalization. A therapeutic improvement of compliance is superior to other measures of afterload in predicting RVFnRec. RVFnRec is also associated with increased RV output reserve at exercise. Clinical Perspective What is new?: Right ventricular functional recovery (RVFnRec) represents a novel endpoint of therapeutic success in PAH. We define RVFnRec as treatment associated normative RV changes related to function (peak oxygen consumption). Normative RV imaging changes are compared to a well phenotyped age, sex, and race/ethnicity matched healthy control cohort from the PVDOMICS project. Previous studies have focused on RV ejection fraction improvements. However, we show that changes in RVEDV are perhaps more important in that improvements in LV function also occur. Lastly, RVFnRec is best predicted by improvements in pulmonary artery compliance versus pulmonary vascular resistance, a more often cited metric of RV afterload.What are the clinical implications?: RVFnRec represents a potential non-invasive assessment of clinical improvement and therapeutic response. Clinicians with access to cardiac MRI can obtain a limited scan (i.e., ventricular volumes) before and after treatment. Future study should examine echocardiographic correlates of RVFnRec.
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26
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Simonneau G, Fadel E, Vonk Noordegraaf A, Toshner M, Lang IM, Klok FA, McInnis MC, Screaton N, Madani MM, Martinez G, Salaunkey K, Jenkins DP, Matsubara H, Brénot P, Hoeper MM, Ghofrani HA, Jaïs X, Wiedenroth CB, Guth S, Kim NH, Pepke-Zaba J, Delcroix M, Mayer E. Highlights from the International Chronic Thromboembolic Pulmonary Hypertension Congress 2021. Eur Respir Rev 2023; 32:32/167/220132. [PMID: 36754432 PMCID: PMC9910339 DOI: 10.1183/16000617.0132-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/14/2022] [Indexed: 02/10/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism. It is caused by persistent obstruction of pulmonary arteries by chronic organised fibrotic clots, despite adequate anticoagulation. The pulmonary hypertension is also caused by concomitant microvasculopathy which may progress without timely treatment. Timely and accurate diagnosis requires the combination of imaging and haemodynamic assessment. Optimal therapy should be individualised to each case and determined by an experienced multidisciplinary CTEPH team with the ability to offer all current treatment modalities. This report summarises current knowledge and presents key messages from the International CTEPH Conference, Bad Nauheim, Germany, 2021. Sessions were dedicated to 1) disease definition; 2) pathophysiology, including the impact of the hypertrophied bronchial circulation, right ventricle (dys)function, genetics and inflammation; 3) diagnosis, early after acute pulmonary embolism, using computed tomography and perfusion techniques, and supporting the selection of appropriate therapies; 4) surgical treatment, pulmonary endarterectomy for proximal and distal disease, and peri-operative management; 5) percutaneous approach or balloon pulmonary angioplasty, techniques and complications; and 6) medical treatment, including anticoagulation and pulmonary hypertension drugs, and in combination with interventional treatments. Chronic thromboembolic pulmonary disease without pulmonary hypertension is also discussed in terms of its diagnostic and therapeutic aspects.
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Affiliation(s)
- Gérald Simonneau
- AP-HP, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Sud, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique and Institut National de la Santé et de la Recherche Médicale Unité 999, Le Kremlin-Bicêtre, France
| | - Elie Fadel
- Research and Innovation Unit, INSERM UMR-S 999, Marie Lannelongue Hospital, Université Paris-Sud, Université Paris-Saclay, Le Plessis-Robinson, France,Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie Lannelongue Hospital, Université Paris-Sud, Université Paris-Saclay, Le Plessis-Robinson, France,Université Paris-Sud and Université Paris-Saclay, School of Medicine, Kremlin-Bicêtre, France
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Universitair Medische Centra, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Mark Toshner
- Royal Papworth Hospital, University of Cambridge, Cambridge, UK
| | - Irene M. Lang
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Frederikus A. Klok
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Micheal C. McInnis
- Department of Medical Imaging, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Michael M. Madani
- Cardiovascular and Thoracic Surgery, University of California-San Diego, La Jolla, CA, USA
| | | | - Kiran Salaunkey
- Royal Papworth Hospital, University of Cambridge, Cambridge, UK
| | | | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Philippe Brénot
- Department of Radiology, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Marius M. Hoeper
- Department of Respiratory Medicine, Hannover Medical School and Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Hossein A. Ghofrani
- Pulmonary Vascular Research, Justus-Liebig University and Pulmonary Hypertension Division, University Hospital Giessen, Giessen, Germany,Department of Pneumology, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Xavier Jaïs
- AP-HP, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Sud, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique and Institut National de la Santé et de la Recherche Médicale Unité 999, Le Kremlin-Bicêtre, France
| | | | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Nick H. Kim
- Division of Pulmonary and Critical Care Medicine, University of California-San Diego, La Jolla, CA, USA
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium .,M. Delcroix and E. Mayer equal contribution (co-last authors)
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany,Meeting organiser,M. Delcroix and E. Mayer equal contribution (co-last authors)
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27
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Richter M, Tello K. Pulmonale Hypertonie – Update Diagnostik und Screening. Aktuelle Kardiologie 2023. [DOI: 10.1055/a-1948-4626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
ZusammenfassungDie pulmonale Hypertonie (PH) ist eine multifaktorielle pulmonalvaskuläre Erkrankung. Bei Patienten mit Belastungsdyspnoe sollte an eine PH als seltene Differenzialdiagnose gedacht werden.
Im klinischen Alltag ist die wichtigste Screeningmethode die Echokardiografie. Zentral zur Stellung der Verdachtsdiagnose ist die Bestimmung der maximalen Geschwindigkeit des
Regurgitationsjets über der Trikuspidalklappe. Zusätzlich berücksichtigt werden sollten weitere echokardiografische PH-Zeichen wie die Dilatation des rechten Vorhofs oder des Ventrikels. Die
Diagnose einer pulmonalen Hypertonie kann abschließend nur im Rechtsherzkatheter gestellt werden. In den neuesten Leitlinien wurde die hämodynamische Definition der PH verändert. Der
mittlere pulmonalarterielle Druck zur Diagnosestellung einer PH wurde aktuell auf > 20 mmHg gesenkt. Gerade im Hinblick auf die neue hämodynamische Definition ist die sorgfältige
Diagnosestellung in einem erfahrenen PH-Zentrum entscheidend.
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Affiliation(s)
- Manuel Richter
- Pulmonal Hypertonie Ambulanz, Medizinische Klinik II, Justus-Liebig-Universität Gießen, Gießen, Deutschland
| | - Khodr Tello
- Pulmonal Hypertonie Ambulanz, Medizinische Klinik II, Justus-Liebig-Universität Gießen, Gießen, Deutschland
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Verwerft J, Bertrand PB, Claessen G, Herbots L, Verbrugge FH. Cardiopulmonary Exercise Testing With Simultaneous Echocardiography: Blueprints of a Dyspnea Clinic for Suspected HFpEF. JACC Heart Fail 2023; 11:243-249. [PMID: 36754531 DOI: 10.1016/j.jchf.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/01/2022] [Accepted: 11/09/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Jan Verwerft
- Department of Cardiology, Hartcentrum, Jessa Hospital, Hasselt, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Philippe B Bertrand
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium; Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Guido Claessen
- Department of Cardiovascular Diseases, University Hospital Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Lieven Herbots
- Department of Cardiology, Hartcentrum, Jessa Hospital, Hasselt, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium; Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.
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Omote K, Verbrugge FH, Sorimachi H, Omar M, Popovic D, Obokata M, Reddy YNV, Borlaug BA. Central haemodynamic abnormalities and outcome in patients with unexplained dyspnoea. Eur J Heart Fail 2023; 25:185-196. [PMID: 36420788 PMCID: PMC9974926 DOI: 10.1002/ejhf.2747] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/26/2022] Open
Abstract
AIMS Little data are available regarding prognostic implications of invasive exercise testing in heart failure with preserved ejection fraction (HFpEF). The present study aimed to investigate whether rest and exercise central haemodynamic abnormalities are associated with adverse clinical outcomes in patients with dyspnea. METHODS AND RESULTS Patients with exertional dyspnoea and ejection fraction ≥50% (n = 764) underwent invasive exercise testing and follow-up for heart failure hospitalization or death. There were 117 patients with events over a median follow-up of 2.7 (interquartile range 0.5-4.6) years. Among patients with normal resting pulmonary artery wedge pressure (PAWP) (<15 mmHg, n = 380 [50%]), increased exercise PAWP (≥25 mmHg) was present in 187 (24% of cohort) and was associated with 2.4-fold higher risk of events compared to those with normal exercise PAWP (<25 mmHg, n = 193 [25%]) (hazard ratio [HR] 2.44; 95% confidence interval [CI] 1.11-5.36; p = 0.03), while patients with elevated resting PAWP (≥15 mmHg, n = 384 [50%]) displayed even higher risk compared to HFpEF with normal resting PAWP (HR 2.24; 95% CI 1.38-3.65; p = 0.001). Similar findings were observed for rest/exercise right atrial pressure, and rest/exercise pulmonary artery pressures. Higher peak oxygen consumption was associated with decreased risk of events, and this relationship was solely explained by exercise cardiac output. In a multivariable-adjusted Cox model, each 1 standard deviation (SD) increase in exercise PAWP was associated with a 41% greater hazard of events (HR 1.41; 95% CI 1.13-1.76; p = 0.002), while each 1 SD decrease in exercise cardiac output was associated with a 37% increased risk (HR 0.63; 95% CI 0.47-0.83; p = 0.001). CONCLUSIONS Haemodynamic abnormalities currently used for diagnosis of HFpEF are associated with increased risk for adverse events. Treatments that reduce central pressures while improving cardiac output reserve may offer greatest benefit to improve outcomes in HFpEF.
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Affiliation(s)
- Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Frederik H. Verbrugge
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Massar Omar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Dejana Popovic
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Yogesh N. V. Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
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30
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Mastoris I, Campain J, Lewis GD. Invasive exercise haemodynamics: an oracle in heart failure with preserved ejection fraction diagnosis and prognostication. Eur J Heart Fail 2023; 25:197-200. [PMID: 36644824 DOI: 10.1002/ejhf.2774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/08/2023] [Indexed: 01/17/2023] Open
Affiliation(s)
- Ioannis Mastoris
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph Campain
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Gregory D Lewis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Kagami K, Obokata M, Harada T, Sorimachi H, Yuasa N, Saito Y, Kato T, Wada N, Adachi T, Ishii H. Incremental diagnostic value of post-exercise lung congestion in heart failure with preserved ejection fraction. Eur Heart J Cardiovasc Imaging 2023; 24:553-561. [PMID: 36691846 DOI: 10.1093/ehjci/jead007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 01/06/2023] [Indexed: 01/25/2023] Open
Abstract
AIMS Lung ultrasound (LUS) may unmask occult heart failure with preserved ejection fraction (HFpEF) by demonstrating an increase in extravascular lung water (EVLW) during exercise. Here, we sought to examine the dynamic changes in ultrasound B-lines during exercise to identify the optimal timeframe for HFpEF diagnosis. METHODS AND RESULTS Patients with HFpEF (n = 134) and those without HF (controls, n = 121) underwent a combination of exercise stress echocardiography and LUS with simultaneous expired gas analysis to identify exercise EVLW. Exercise EVLW was defined by B-lines that were newly developed or increased during exercise. The E/e' ratio peaked during maximal exercise and immediately decreased during the recovery period in patients with HFpEF. Exercise EVLW was most prominent during the recovery period in patients with HFpEF, while its prevalence did not increase from peak exercise to the recovery period in controls. Exercise EVLW was associated with a higher E/e' ratio and pulmonary artery pressure, lower right ventricular systolic function, and elevated minute ventilation to carbon dioxide production (VE vs. VCO2) slope during peak exercise. Increases in B-lines from rest to the recovery period provided an incremental diagnostic value to identify HFpEF over the H2FPEF score and resting left atrial reservoir strain. CONCLUSION Exercise EVLW was most prominent early during the recovery period; this may be the optimal timeframe for imaging ultrasound B-lines. Exercise stress echocardiography with assessments of recovery EVLW may enhance the diagnosis of HFpEF.
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Affiliation(s)
- Kazuki Kagami
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan.,Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Tomonari Harada
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Naoki Yuasa
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Yuki Saito
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Toshimitsu Kato
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Naoki Wada
- Department of Rehabilitation Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Takeshi Adachi
- Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
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Khattab E, Velidakis N, Gkougkoudi E, Kadoglou NP. Exercise-Induced Pulmonary Hypertension: A Valid Entity or Another Factor of Confusion? Life (Basel) 2023; 13:life13010128. [PMID: 36676077 PMCID: PMC9860538 DOI: 10.3390/life13010128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 01/05/2023]
Abstract
Exercise-induced pulmonary hypertension EIPH has been defined as an increase in mean pulmonary arterial pressure (mPAP) during exercise in otherwise normal values at rest. EIPH reflects heart and/or lung dysfunction and may precede the development of manifest pulmonary hypertension (PH) in a proportion of patients. It is also associated with decreased life expectancy in patients with heart failure with reduced ejection fraction (HFrEF) or left ventricle (LV) valvular diseases. Diastolic dysfunction exacerbated during exercise relates to increased LV filling pressure and left atrial pressure (LAP). In this context backward, transmitted pressure alone or accompanied with backward blood flow promotes EIPH. The gold standard of EIPH assessment remains the right heart catheterization during exercise, which is an accurate but invasive method. Alternatively, non-invasive diagnostic modalities include exercise stress echocardiography (ESE) and cardiopulmonary exercise testing (CPET). Both diagnostic tests are performed under gradually increasing physical stress using treadmill and ergo-cycling protocols. Escalating workload during the exercise is analogous to the physiological response to real exercise. The results of the latter techniques show good correlation with invasive measurements, but they suffer from lack of validation and cut-off value determination. Although it is not officially recommended, there are accumulated data supporting the importance of EIPH diagnosis in the assessment of other mild/subclinical or probably fatal diseases in patients with latent PH or heart failure or LV valvular disease, respectively. Nevertheless, larger, prospective studies are required to ensure its role in clinical practice.
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Swisher JW, Weaver E. The Evolving Management and Treatment Options for Patients with Pulmonary Hypertension: Current Evidence and Challenges. Vasc Health Risk Manag 2023; 19:103-126. [PMID: 36895278 PMCID: PMC9990521 DOI: 10.2147/vhrm.s321025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 02/01/2023] [Indexed: 03/06/2023] Open
Abstract
Pulmonary hypertension may develop as a disease process specific to pulmonary arteries with no identifiable cause or may occur in relation to other cardiopulmonary and systemic illnesses. The World Health Organization (WHO) classifies pulmonary hypertensive diseases on the basis of primary mechanisms causing increased pulmonary vascular resistance. Effective management of pulmonary hypertension begins with accurately diagnosing and classifying the disease in order to determine appropriate treatment. Pulmonary arterial hypertension (PAH) is a particularly challenging form of pulmonary hypertension as it involves a progressive, hyperproliferative arterial process that leads to right heart failure and death if untreated. Over the last two decades, our understanding of the pathobiology and genetics behind PAH has evolved and led to the development of several targeted disease modifiers that ameliorate hemodynamics and quality of life. Effective risk management strategies and more aggressive treatment protocols have also allowed better outcomes for patients with PAH. For those patients who experience progressive PAH with medical therapy, lung transplantation remains a life-saving option. More recent work has been directed at developing effective treatment strategies for other forms of pulmonary hypertension, such as chronic thromboembolic pulmonary hypertension (CTEPH) and pulmonary hypertension due to other lung or heart diseases. The discovery of new disease pathways and modifiers affecting the pulmonary circulation is an ongoing area of intense investigation.
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Affiliation(s)
- John W Swisher
- East Tennessee Pulmonary Hypertension Center, StatCare Pulmonary Consultants, Knoxville, TN, USA
| | - Eric Weaver
- East Tennessee Pulmonary Hypertension Center, StatCare Pulmonary Consultants, Knoxville, TN, USA
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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: 345] [Impact Index Per Article: 345.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Yanagisawa Y, Goda A, Takeuchi S, Takeuchi K, Kikuchi H, Inami T, Tanigaki S, Kohno T, Soejima K, Satoh T. Successful Management and Risk Stratification by Exercise Right Heart Catheterization before Pregnancy in Patient with Pulmonary Arterial Hypertension. CJC Open 2023; 5:312-314. [PMID: 37124965 PMCID: PMC10140741 DOI: 10.1016/j.cjco.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/17/2023] [Indexed: 01/22/2023] Open
Affiliation(s)
- Yoshiaki Yanagisawa
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
- Corresponding author: Dr Ayumi Goda, Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan. Tel.: +81-422-47-5511; fax: +81-422-44-0683.
| | - Shinsuke Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Kaori Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Hanako Kikuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Takumi Inami
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Shinji Tanigaki
- Department of Obstetrics and Gynecology, Kyorin University Hospital, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
| | - Toru Satoh
- Department of Cardiovascular Medicine, Kyorin University Hospital, Tokyo, Japan
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Biscopink A, Mostertz W, Grewal J, Silverman DN, Masarone D, Tedford RJ. Interatrial Septal Devices for HFpEF: What We Learned from REDUCE LAP-HF. Curr Treat Options Cardio Med 2022. [DOI: 10.1007/s11936-022-00975-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Zeder K, Olschewski H, Kovacs G. Updated definition of exercise pulmonary hypertension. Breathe (Sheff) 2022; 18:220232. [PMID: 36865934 PMCID: PMC9973500 DOI: 10.1183/20734735.0232-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/02/2022] [Indexed: 02/16/2023] Open
Abstract
In the recently published European Society of Cardiology/European Respiratory Society guidelines on the diagnosis and treatment of pulmonary hypertension (PH) the haemodynamic definitions of PH were updated and a new definition for exercise PH was introduced. Accordingly, exercise PH is characterised by a mean pulmonary arterial pressure/cardiac output (CO) slope >3 Wood units (WU) from rest to exercise. This threshold is supported by several studies demonstrating prognostic and diagnostic relevance of exercise haemodynamics in various patient cohorts. From a differential diagnostic point of view, an elevated pulmonary arterial wedge pressure/CO slope >2 WU may be suitable to identify post-capillary causes of exercise PH. Right heart catheterisation remains the gold standard to assess pulmonary haemodynamics both at rest and exercise. In this review, we discuss the evidence that led to the reintroduction of exercise PH in the PH definitions.
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Affiliation(s)
- Katarina Zeder
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Horst Olschewski
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Gabor Kovacs
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria,Corresponding author: Gabor Kovacs ()
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39
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Montané B, Tonelli AR, Arunachalam A, Bhattacharyya A, Li M, Wang X, Chaisson NF. Hemodynamic Responses to Provocative Maneuvers during Right Heart Catheterization. Ann Am Thorac Soc 2022; 19:1977-85. [PMID: 35802812 DOI: 10.1513/AnnalsATS.202201-077OC] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Rationale: Current guidelines recognize the utility of provocative maneuvers during right heart catheterization to aid the diagnosis of pulmonary hypertension. Few studies have compared the performance of different provocation maneuvers. Objectives: To assess the hemodynamic correlation among three provocative maneuvers, including their effect on pulmonary hypertension classification. Methods: This prospective trial was conducted between October 2016 and May 2018. Adult patients underwent three provocative maneuvers during right heart catheterization: passive leg raise (PLR), load-targeted supine bicycle exercise, and rapid crystalloid fluid infusion. Patients were classified as follows: no pulmonary hypertension, precapillary pulmonary hypertension, isolated postcapillary pulmonary hypertension, combined pre- and postcapillary pulmonary hypertension, and uncategorized pulmonary hypertension. We assessed the hemodynamic changes associated with each maneuver. We also assessed whether provocative maneuvers led to hemodynamic reclassification of the patient to either postcapillary pulmonary hypertension with provocation or exercise pulmonary hypertension. Results: Eighty-five patients (mean age 62 ± 12 years, 53% women) were included. Correlation between exercise and fluid challenge was moderate to strong (0.49-0.82; P < 0.001) for changes in right atrial pressure, mean pulmonary arterial pressure, pulmonary arterial wedge pressure, and cardiac index from baseline. Correlation between PLR and exercise (0.4-0.65; P < 0.001) and between PLR and fluid challenge (0.45-0.6; P < 0.001) was moderate for changes in right atrial pressure, mean pulmonary arterial pressure, pulmonary arterial wedge pressure, pulmonary vascular resistance, and cardiac index. Hemodynamic correlation between other provocative maneuvers was poor. Depending on provocative maneuver and classification criteria, there was significant variation in the number of patients reclassified as having exercise pulmonary hypertension (3-50%) or postcapillary pulmonary hypertension with provocation (11-48%). Conclusions: Hemodynamic determinations during exercise and fluid challenge showed moderate to strong hemodynamic correlation. Moderate hemodynamic correlation was seen between PLR and exercise or fluid challenge. Although some provocative maneuvers demonstrate good hemodynamic correlation, there is inconsistency when using these maneuvers to identify patients with postcapillary or exercise pulmonary hypertension.
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40
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Douschan P, Avian A, Foris V, Sassmann T, Bachmaier G, Rosenstock P, Zeder K, Olschewski H, Kovacs G. Prognostic Value of Exercise as Compared to Resting Pulmonary Hypertension in Patients with Normal or Mildly Elevated Pulmonary Arterial Pressure. Am J Respir Crit Care Med 2022; 206:1418-1423. [PMID: 35925022 PMCID: PMC9746857 DOI: 10.1164/rccm.202112-2856le] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Philipp Douschan
- Medical University of GrazGraz, Austria,Ludwig Boltzmann Institute for Lung Vascular ResearchGraz, Austria,Corresponding author (e-mail: )
| | | | - Vasile Foris
- Medical University of GrazGraz, Austria,Ludwig Boltzmann Institute for Lung Vascular ResearchGraz, Austria
| | - Teresa Sassmann
- Medical University of GrazGraz, Austria,Ludwig Boltzmann Institute for Lung Vascular ResearchGraz, Austria
| | | | - Piet Rosenstock
- Medical University of GrazGraz, Austria,Ludwig Boltzmann Institute for Lung Vascular ResearchGraz, Austria
| | - Katarina Zeder
- Medical University of GrazGraz, Austria,Ludwig Boltzmann Institute for Lung Vascular ResearchGraz, Austria
| | - Horst Olschewski
- Medical University of GrazGraz, Austria,Ludwig Boltzmann Institute for Lung Vascular ResearchGraz, Austria
| | - Gabor Kovacs
- Medical University of GrazGraz, Austria,Ludwig Boltzmann Institute for Lung Vascular ResearchGraz, Austria
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Kriechbaum SD, Birmes J, Wiedenroth CB, Adameit MSD, Gruen D, Vietheer J, Richter MJ, Guth S, Roller FC, Rademann M, Fischer-Rasokat U, Rolf A, Liebetrau C, Hamm CW, Keller T, Rieth AJ. Exercise MR-proANP unmasks latent right heart failure in CTEPH. J Heart Lung Transplant 2022; 41:1819-1830. [PMID: 36210266 DOI: 10.1016/j.healun.2022.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/31/2022] [Accepted: 08/22/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The present study was designed to investigate the dynamics of right atrial pressure (RAP) and mid-regional pro-atrial natriuretic peptide (MR-proANP) during physical exercise in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and to determine whether these parameters might serve as a tool to measure exercise-dependent atrial stress as an indicator of right heart failure. METHODS This prospective observational cohort study included 100 CTEPH patients who underwent right heart catheterization during physical exercise (eRHC). Blood samples for MR-proANP measurement were taken prior, during, and after eRHC. MR-proANP levels were correlated to RAP levels at rest, at peak exercise (eRAP), and during recovery. RAP at rest ≤7 mmHg was defined as normal and eRAP >15 mmHg as suggestive of right heart failure. RESULTS During eRHC mean RAP increased from 6 mmHg (standard deviation, SD 4) to 16 mmHg (SD 7; p < 0.001). MR-proANP levels and dynamics correlated with RAP at rest (rs = 0.61; p < 0.001) and at peak exercise (rs = 0.66; p < 0.001). Logistic regression analysis revealed the peak MR-proANP level (B = 0.058; p = 0.004) and the right atrial area (B = 0.389; p < 0.001) to be associated with eRAP dynamics. A peak MR-proANP level ≥139 pmol/L (AUC = 0.81) and recovery level ≥159 pmol/L (AUC = 0.82) predicted an eRAP >15 mmHg. Physical exercise unmasked right heart failure in 39% of patients with normal RAP at rest; these patients were also characterized by a more distinct increase in MR-proANP levels (p = 0.005) and higher peak (p < 0.001) and recovery levels (p < 0.001). CONCLUSIONS RAP and MR-proANP dynamics unmask manifest and latent right heart failure in CTEPH patients.
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Affiliation(s)
- Steffen D Kriechbaum
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany.
| | - Judith Birmes
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany
| | - Christoph B Wiedenroth
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Miriam S D Adameit
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Dimitri Gruen
- Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - J Vietheer
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany
| | - Manuel J Richter
- Department of Pneumology, Kerckhoff-Klinik, Bad Nauheim, Germany; Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Stefan Guth
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Fritz C Roller
- Justus Liebig University Giessen, Department of Radiology, Giessen, Germany
| | - Matthias Rademann
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - Ulrich Fischer-Rasokat
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Andreas Rolf
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany; Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Christoph Liebetrau
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany; Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | - Christian W Hamm
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany; Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Till Keller
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany; Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Andreas J Rieth
- Campus Kerckhoff, University of Giessen, Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany
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Montani D, Jutant EM, Simonneau G, Humbert M. Nouvelles définitions et classification de l’hypertension pulmonaire. Bulletin de l'Académie Nationale de Médecine 2022. [DOI: 10.1016/j.banm.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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43
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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: 881] [Impact Index Per Article: 440.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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44
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Douschan P, Kovacs G, Sassmann T, Stadlbauer V, Avian A, Foris V, Tatscher E, Durchschein F, Rainer F, Spindelboeck W, Wagner M, Kniepeiss D, Zollner G, Bachmaier G, Fickert P, Olschewski H, Stauber RE. Pulmonary vascular disease and exercise hemodynamics in chronic liver disease. Respir Med 2022; 202:106987. [PMID: 36115317 DOI: 10.1016/j.rmed.2022.106987] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/27/2022] [Accepted: 09/06/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND & AIMS Portopulmonary hypertension (POPH) and hepatopulmonary syndrome (HPS) are severe pulmonary vascular complications of chronic liver disease and strongly associated with morbidity and mortality. The prevalence of these complications is relatively high in patients evaluated for liver transplantation, however it is virtually unknown in patients with stable chronic liver disease. METHODS We assessed the pulmonary hypertension (PH) and HPS prevalence in a prospective registry study of our liver out-patient clinic in a tertiary center. Between 2011 and 2016, consecutive patients with cirrhosis or non-cirrhotic portal hypertension were prospectively enrolled after written informed consent. We excluded patients with acute decompensation of liver disease and other causes of PH like severe chronic heart or lung diseases and chronic thromboembolic PH. HPS was diagnosed using contrast enhanced echocardiography and blood gas analysis. Patients were screened for PH using an algorithm implementing severity of dyspnea, echocardiography, cardiopulmonary exercise testing and exercise echocardiography employing a threshold of systolic pulmonary arterial pressure (SPAP) = 50 mmHg at peak exercise. If the algorithm indicated an increased PH risk, patients were invited for invasive investigations by means of right heart and hepatic vein catheter. We defined POPH as resting mPAP≥21 mmHg and PVR>3WU and PAWP<15 mmHg, mild PH as resting mPAP = 21-24 mmHg, and exercise PH as mPAP>30 mmHg and TPR >3 WU at peak exercise. RESULTS Two-hundred-five patients were enrolled (male 75%; cirrhosis 96%; median age 57 yrs). Sixty-seven patients (33%) fulfilled HPS criteria but only two (1.0%) for severe (PaO2:50-60 mmHg) or very severe HPS (PaO2<50 mmHg). In 18/77 patients (23%) undergoing exercise echocardiography, SPAP at peak exercise exceeded 50 mmHg. Finally, n = 3 (1.5%) patients were invasively diagnosed with POPH, n = 4 (2.9%) with mild PH and n = 2 with exercise PH. CONCLUSION In chronic liver disease, excluding acute decompensation and other causes of PH, POPH and severe HPS are rare findings while mild to moderate HPS and mild PH or exercise PH are more frequent.
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Affiliation(s)
- Philipp Douschan
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Gabor Kovacs
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.
| | - Teresa Sassmann
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Vanessa Stadlbauer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Vasile Foris
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Elisabeth Tatscher
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Franziska Durchschein
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Florian Rainer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Walter Spindelboeck
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Martin Wagner
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Daniela Kniepeiss
- Department of General, Visceral and Transplant Surgery, Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Gernot Zollner
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Gerhard Bachmaier
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Peter Fickert
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Horst Olschewski
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria; Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Rudolf E Stauber
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
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Baratto C, Caravita S, Soranna D, Dewachter C, Bondue A, Zambon A, Badano LP, Parati G, Vachiéry J. Exercise haemodynamics in heart failure with preserved ejection fraction: a systematic review and meta-analysis. ESC Heart Fail 2022; 9:3079-3091. [PMID: 35748109 PMCID: PMC9715813 DOI: 10.1002/ehf2.13979] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 04/08/2022] [Accepted: 05/08/2022] [Indexed: 11/08/2022] Open
Abstract
AIMS Exercise right heart catheterization (RHC) is considered the gold-standard test to diagnose heart failure with preserved ejection fraction (HFpEF). However, exercise RHC is an insufficiently standardized technique, and current haemodynamic thresholds to define HFpEF are not universally accepted. We sought to describe the exercise haemodynamics profile of HFpEF cohorts reported in literature, as compared with control subjects. METHODS AND RESULTS We performed a systematic literature review until December 2020. Studies reporting pulmonary artery wedge pressure (PAWP) at rest and peak exercise were extracted. Summary estimates of all haemodynamic variables were evaluated, stratified according to body position (supine/upright exercise). The PAWP/cardiac output (CO) slope during exercise was extrapolated. Twenty-seven studies were identified, providing data for 2180 HFpEF patients and 682 controls. At peak exercise, patients with HFpEF achieved higher PAWP (30 [29-31] vs. 16 [15-17] mmHg, P < 0.001) and mean right atrial pressure (P < 0.001) than controls. These differences persisted after adjustment for age, sex, body mass index, and body position. However, peak PAWP values were highly heterogeneous among the cohorts (I2 = 93%), with a relative overlap with controls. PAWP/CO slope was steeper in HFpEF than in controls (3.75 [3.20-4.28] vs. 0.95 [0.30-1.59] mmHg/L/min, P value < 0.0001), even after adjustment for covariates (P = 0.007). CONCLUSIONS Despite methodological heterogeneity, as well as heterogeneity of pooled haemodynamic estimates, the exercise haemodynamic profile of HFpEF patients is consistent across studies and characterized by a steep PAWP rise during exercise. More standardization of exercise haemodynamics may be advisable for a wider application in clinical practice.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
- Department of CardiologyHopital Universitaire de Bruxelles, Hôpital Académique Erasme808 Route de Lennik1070BruxellesBelgium
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
- Department of Management, Information and Production EngineeringUniversity of BergamoDalmineItaly
| | - Davide Soranna
- Biostatistics UnitIRCCS Istituto Auxologico ItalianoMilanItaly
| | - Céline Dewachter
- Department of CardiologyHopital Universitaire de Bruxelles, Hôpital Académique Erasme808 Route de Lennik1070BruxellesBelgium
| | - Antoine Bondue
- Department of CardiologyHopital Universitaire de Bruxelles, Hôpital Académique Erasme808 Route de Lennik1070BruxellesBelgium
| | - Antonella Zambon
- Biostatistics UnitIRCCS Istituto Auxologico ItalianoMilanItaly
- Department of Statistic and Quantitative MethodsUniversity of Milano‐BicoccaMilanItaly
| | - Luigi P. Badano
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | - Jean‐Luc Vachiéry
- Department of CardiologyHopital Universitaire de Bruxelles, Hôpital Académique Erasme808 Route de Lennik1070BruxellesBelgium
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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: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Lee MH, Menezes TCF, Reisz JA, Ferreira EVM, Graham BB, Oliveira RKF. Exercise metabolomics in pulmonary arterial hypertension: Where pulmonary vascular metabolism meets exercise physiology. Front Physiol 2022; 13:963881. [PMID: 36171971 PMCID: PMC9510894 DOI: 10.3389/fphys.2022.963881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/23/2022] [Indexed: 01/29/2023] Open
Abstract
Pulmonary arterial hypertension is an incurable disease marked by dysregulated metabolism, both at the cellular level in the pulmonary vasculature, and at the whole-body level characterized by impaired exercise oxygen consumption. Though both altered pulmonary vascular metabolism and abnormal exercise physiology are key markers of disease severity and pulmonary arterial remodeling, their precise interactions are relatively unknown. Herein we review normal pulmonary vascular physiology and the current understanding of pulmonary vascular cell metabolism and cardiopulmonary response to exercise in Pulmonary arterial hypertension. We additionally introduce a newly developed international collaborative effort aimed at quantifying exercise-induced changes in pulmonary vascular metabolism, which will inform about underlying pathophysiology and clinical management. We support our investigative approach by presenting preliminary data and discuss potential future applications of our research platform.
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Affiliation(s)
- Michael H. Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Thaís C. F. Menezes
- Division of Respiratory Diseases, Department of Medicine, Federal University of SP, São Paulo, Brazil
| | - Julie A. Reisz
- Department of Biochemistry and Molecular Genetics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Eloara V. M. Ferreira
- Division of Respiratory Diseases, Department of Medicine, Federal University of SP, São Paulo, Brazil
| | - Brian B. Graham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Rudolf K. F. Oliveira
- Division of Respiratory Diseases, Department of Medicine, Federal University of SP, São Paulo, Brazil,*Correspondence: Rudolf K. F. Oliveira,
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Desole S, Obst A, Habedank D, Opitz CF, Knaack C, Hortien F, Heine A, Stubbe B, Ewert R. Comparison between thermodilution and Fick methods for resting and exercise‐induced cardiac output measurement in patients with chronic dyspnea. Pulm Circ 2022; 12:e12128. [PMID: 36051350 PMCID: PMC9425001 DOI: 10.1002/pul2.12128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 06/07/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
Studies comparing thermodilution (TD) and the direct Fick method (dFM) for cardiac output (CO) measurement are rare. We compared CO measurements between TD (2–5 cold water injections), the dFM, and indirect Fick method (iFM) at rest and during exercise, and assessed the effect of averaging different numbers of TD measurements during exercise. This retrospective study included 300 patients (52.3% women, mean age 66 ± 11 years) having pulmonary hypertension (76.0%) or unexplained dyspnea. Invasive hemodynamic and gas exchange parameters were measured at rest (supine; n = 300) and during unloaded cycling (semi‐supine; n = 275) and 25‐W exercise (semi‐supine; n = 240). All three methods showed significant differences in CO measurement (ΔCO) at rest (p ≤ 0.001; ΔCO > 1 L/min: 45.0% [iFM vs. dFM], 42.0% [iFM vs. TD], and 45.7% [TD vs. dFM]). ΔCO (TD vs. dFM) was significant during unloaded cycling (p < 0.001; ΔCO > 1 L/min: 56.6%) but not during 25‐W exercise (p = 0.137; ΔCO > 1 L/min: 52.8%). ΔCO (TD vs. dFM) during 25‐W exercise was significant when using one or two (p ≤ 0.01) but not three (p = 0.06) TD measurements. Mean ΔCO (TD [≥3 measurements] vs. dFM) was −0.43 ± 1.98 and −0.06 ± 2.29 L/min during unloaded and 25‐W exercise, respectively. Thus, TD and dFM CO measurements are comparable during 25‐W exercise (averaging ≥3 TD measurements), but not during unloaded cycling or at rest. Individual ΔCOs vary substantially and require critical interpretation to avoid CO misclassification.
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Affiliation(s)
- Susanna Desole
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Anne Obst
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Dirk Habedank
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
- Division of Cardiology, Department of Internal MedicineDRK‐HospitalBerlinGermany
| | - Christian F. Opitz
- Division of Cardiology, Department of Internal MedicineDRK‐HospitalBerlinGermany
| | - Christine Knaack
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Franziska Hortien
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Alexander Heine
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Beate Stubbe
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
| | - Ralf Ewert
- Division of Pneumology, Department of Internal Medicine BUniversity Hospital GreifswaldGreifswaldGermany
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Douschan P, Tello K, Rieth AJ, Wiedenroth CB, Sassmann T, Kovacs G, Ghofrani HA, Seeger W, Richter M, Guth S. Right ventricular-pulmonary arterial coupling and its relationship to exercise haemodynamics in a continuum of patients with pulmonary vascular disease due to chronic thromboembolism. Eur Respir J 2022; 60:13993003.00450-2022. [PMID: 35953102 DOI: 10.1183/13993003.00450-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/22/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Philipp Douschan
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig-University, Giessen, Germany.,Department of Internal Medicine, Division of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.,These two authors contributed equally to this article
| | - Khodr Tello
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig-University, Giessen, Germany.,These two authors contributed equally to this article
| | - Andreas J Rieth
- Department of Cardiology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Teresa Sassmann
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Gabor Kovacs
- Department of Internal Medicine, Division of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Hossein A Ghofrani
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig-University, Giessen, Germany.,Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,Department of Medicine, Imperial College London, London, UK
| | - Werner Seeger
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig-University, Giessen, Germany
| | - Manuel Richter
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Institute for Lung Health (ILH), Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig-University, Giessen, Germany.,These two authors contributed equally to this article
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany .,These two authors contributed equally to this article
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Langleben D, Orfanos SE, Fox BD, Messas N, Giovinazzo M, Catravas JD. The Paradox of Pulmonary Vascular Resistance: Restoration of Pulmonary Capillary Recruitment as a Sine Qua Non for True Therapeutic Success in Pulmonary Arterial Hypertension. J Clin Med 2022; 11:jcm11154568. [PMID: 35956182 PMCID: PMC9369805 DOI: 10.3390/jcm11154568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/21/2022] [Accepted: 08/03/2022] [Indexed: 12/14/2022] Open
Abstract
Exercise-induced increases in pulmonary blood flow normally increase pulmonary arterial pressure only minimally, largely due to a reserve of pulmonary capillaries that are available for recruitment to carry the flow. In pulmonary arterial hypertension, due to precapillary arteriolar obstruction, such recruitment is greatly reduced. In exercising pulmonary arterial hypertension patients, pulmonary arterial pressure remains high and may even increase further. Current pulmonary arterial hypertension therapies, acting principally as vasodilators, decrease calculated pulmonary vascular resistance by increasing pulmonary blood flow but have a minimal effect in lowering pulmonary arterial pressure and do not restore significant capillary recruitment. Novel pulmonary arterial hypertension therapies that have mainly antiproliferative properties are being developed to try and diminish proliferative cellular obstruction in precapillary arterioles. If effective, those agents should restore capillary recruitment and, during exercise testing, pulmonary arterial pressure should remain low despite increasing pulmonary blood flow. The effectiveness of every novel therapy for pulmonary arterial hypertension should be evaluated not only at rest, but with measurement of exercise pulmonary hemodynamics during clinical trials.
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Affiliation(s)
- David Langleben
- Center for Pulmonary Vascular Disease, Azrieli Heart Center and Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
- Correspondence: ; Tel.: +1-514-340-7531
| | - Stylianos E. Orfanos
- 1st Department of Critical Care and Pulmonary Services, Pulmonary Hypertension Center, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, 10676 Athens, Greece
| | - Benjamin D. Fox
- Pulmonary Division, Yitzchak Shamir Hospital, Tel Aviv University, Tzrifin 69978, Israel
| | - Nathan Messas
- Center for Pulmonary Vascular Disease, Azrieli Heart Center and Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
| | - Michele Giovinazzo
- Center for Pulmonary Vascular Disease, Azrieli Heart Center and Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
| | - John D. Catravas
- Frank Reidy Research Center for Bioelectrics, Old Dominion University, Norfolk, VA 23529, USA
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