Diagnosis and Treatment Patterns of Chronic Thromboembolic Pulmonary Hypertension in Russia, Kazakhstan, Turkey, Lebanon, and Saudi Arabia: A Registry Study

BACKGROUND

Patients with chronic thromboembolic pulmonary hypertension (CTEPH) in countries with limited resources have, to date, been poorly represented in registries.

OBJECTIVE

This work assesses the epidemiology, diagnosis, hemodynamic and functional parameters, and treatment of CTEPH in Russia, Kazakhstan, Turkey, Lebanon, and Saudi Arabia.

METHODS

A prospective, cohort, phase IV, observational registry with 3-year follow-up (n = 212) in patients aged ≥ 18 years diagnosed with CTEPH was created. Clinical, hemodynamic, and functional parameters were obtained at an initial visit, follow-up visits, and a final visit at the end of 3 years' observation or end of follow-up. Data were recorded on electronic case report forms. Parameters evaluated included 6-minute walking distance (6MWD), use of pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA), pulmonary hypertension (PH)-targeted therapy, and survival. All statistical analyses were exploratory and descriptive, and were performed in the overall population.

RESULTS

The most common symptoms were typical of those expected for CTEPH. Almost 90% of patients underwent right heart catheterization at diagnosis or initial study visit. In total, 66 patients (31%) underwent PEA before the initial visit; 95 patients (45%) were considered operable, 115 (54%) were inoperable, and two (1%) had no operability data. Only 26 patients (12%) had been assessed for BPA at their initial visit. PH-targeted therapy was documented at diagnosis for 77 patients (36%), most commonly a phosphodiesterase type 5 inhibitor (23%). Use of PH-targeted therapy increased to 142 patients (67%) at the initial visit, remaining similar after 3 years. Use of riociguat increased from 6% of patients at diagnosis to 38% at 3 years. Between baseline and end of observation, results for patients with paired data showed an increase in 6MWD. Survival at the end of observation was 88%.

CONCLUSIONS

These data highlight the current diagnosis and management of CTEPH in the participating countries. They show that early CTEPH diagnosis remains challenging, and use of off-label PH-targeted therapy is common.

CLINICALTRIALS

gov: NCT02637050; registered December 2015.

Which Diastolic Pressure Should Be Used to Assess Diastolic Function?

BACKGROUND

Although high left ventricular filling pressures [left ventricular (LV) end-diastolic pressure or pulmonary capillary wedge pressure (PCWP)] are widely taken as surrogates for LV diastolic dysfunction, the actual distending pressure that governs LV diastolic stretch is transmural pressure difference (∆PTM). Clinically, preferring ∆PTM over PCWP may improve diagnostic and therapeutic decision-making. We aimed to compare the clinical implications of diastolic function characterization based on PCWP or ∆PTM.

METHODS

We retrospectively screened our hospital database for adult patients with a clinical diagnosis of heart failure who underwent right heart catheterization. Echocardiographic diastolic dysfunction was graded according to the current guidelines. LV end-diastolic properties were assessed with construction of complete end-diastolic pressure-volume relationship (EDPVR) curves using the single-beat method. Survival status was checked via the electronic national health-care system.

RESULTS

A total of 693 cases were identified in our database; the final study population comprised 621 cases. ∆PTM-based, but not PCWP-based, EDPVR diastolic stiffness constants were significantly predictive of advanced diastolic dysfunction. PCWP-based diastolic stiffness constants were not able to predict 5-year mortality, whereas ∆PTM-based EDPVR stiffness constants and volumes all turned out to have significant predictive power for 5-year mortality.

CONCLUSION

Left ventricular diastolic function assessment can be improved using ∆PTM instead of PCWP. As ∆PTM ultimately linked to right-sided functions, this approach emphasizes the limitations of taking LV diastolic function as an isolated phenomenon and underlines the need for a complete hemodynamic assessment involving the right heart in therapeutic and prognostic decision-making processes.

Is Pulmonary Capillary Wedge Pressure a Reliable Indicator of Postcapillary Pulmonary Hypertension?

Although current pulmonary hypertension (PH) guidelines recommend a pulmonary capillary wedge pressure (PCWP) >15 mm Hg for the detection of a postcapillary component, the rationale of this recommendation may not be quite compatible with the peculiar hemodynamics of PH. We hypothesize that a high PCWP alone does not necessarily indicate left-sided disease, and this diagnosis can be improved using left ventricle transmural pressure difference (∆ PTM). In this 2-center, retrospective, observational study, we enrolled 1,070 patients with PH who underwent heart catheterization, with the final study population comprising 961 cases. ∆ PTM was calculated as PCWP minus right atrial pressure. The patients with group II PH had significantly higher ∆ PTM values (12.6 ± 6.6 mm Hg) compared with the other groups (1.1 ± 4.8 in group I, 12.4 ± 6.6 in group II, 2.5 ± 6.4 in group III, and 0.8 ± 8.0 in group IV, p <0.001) despite overlapping PCWP values. A ∆ PTM cutoff of 7 mm Hg identifies left heart disease when PCWP is >15 (area under curve 0.825, 95% confidence interval 0.784 to 0.866, p <0.001). Five-year mortality was significantly higher in patients with high ∆ PTM and PCWP subgroups compared with low ∆ PTM plus high PCWP (26.1% vs 18.5%, p = 0.027) and low ∆ PTM and PCWP subgroups (26.1% vs 15.6%, p <0.001). ∆ PTM has supplementary discriminatory power in distinguishing patients with and without postcapillary PH. In conclusion, a new approach utilizing ∆ PTM may improve our understanding of PH pathophysiology and may identify a subpopulation that may potentially benefit from PH-specific treatments.

Cardiologists' Awareness of the Relationship Between Periodontal Diseases and Cardiovascular Diseases: A Region-Wide Survey in Türkiye

OBJECTIVE

The relationship between oral health and general health has gained increased attention in recent years. This study sought to assess the knowledge, attitudes, and practices of cardiologists in Türkiye concerning the link between periodontal disease and cardiovascular disease (CVD).

METHODS

After a pilot test, a modified survey was dispatched to 1,894 practicing cardiologists in Türkiye. Two mailings were carried out, and descriptive statistics were used to analyze the data.

RESULTS

Of the 1,894 cardiologists surveyed, 166 responded, yielding a response rate of 11.5%. The majority of respondents (77%) were male and held professional positions in academia (45%), as assistant doctors (17.5%), or in private practice (12.7%). Ninety percent of respondents accurately recognized periodontal disease as a chronic, multifactorial inflammatory disease. Meanwhile, 78% concurred that inflammation is a pivotal connection between periodontal disease and CVD. On the topic of whether treating periodontal disease could reduce a patient's CVD risk, 37% of the polled cardiologists expressed uncertainty, while 9% disagreed. Seventy six percent believed that periodontists and cardiologists should collaborate to reduce shared risk factors for both cardiovascular and periodontal diseases. Additionally, 80% expressed interest in deepening their understanding of the link between periodontitis and CVD.

CONCLUSION

While the vast majority of participants acknowledged that microbially-associated, host-mediated inflammation is a hallmark of periodontitis, consensus was lacking on inflammation being the primary factor linking periodontal diseases and CVDs. The majority of respondents expressed eagerness understand better the relationship between these two diseases, with the intention of enhancing oral health content in medical school and attending relevant seminars.

Evaluation of Pulmonary Hypertension with Exercise Right Heart Catheterization in an Adult Patient with Cor Triatriatum Sinister

Cor triatriatum sinister (CTS) is a rare adult congenital heart disease. The usual presentation may vary according to the size of the hole in the membrane in the left atrium and the pressure gradient. In addition to acute clinical presentations including acute pulmonary edema and sudden cardiac death, patients may present with chronic findings such as right heart failure due to pulmonary hypertension. The development of pulmonary hypertension is an important indicator of mortality. In cases where non-invasive methods are not sufficient for the diagnosis of pulmonary hypertension, exercise right heart catheterization may also be used. We present a patient with CTS, in whom the final decision was made with the help of an exercise right heart catheterization.

Bendopnea Predicts Right Ventricular Energy Failure in Patients with Pulmonary Hypertension

OBJECTIVE

The development of right ventricular failure has a significant adverse prognostic impact on the course of pulmonary hypertension. Right ventricular energy failure has been shown to double the mortality of pulmonary hypertension even after correction for many established risk predictors. We hypothesize that bendopnea may indicate right ventricular energy failure in patients with pulmonary hypertension.

METHODS

We prospectively enrolled patients with pulmonary hypertension who were admitted to our pulmonary hypertension outpatient clinic between January 2021 and June 2021. Bendopnea was assessed by asking patients to bend forward and report any shortness of breath within 30 seconds. Routine physical examination, laboratory tests, echocardiography, and right heart catheterization parameters were collected.

RESULTS

A total of 167 patients were enrolled into the study. Bendopnea and right ventricular energy failure was present in 79 (47.3%) and 43 (25.7%) patients, respectively. Bendopnea accurately predicted the presence of right ventricular energy failure (area under the curve, 0.667; 95% CI, 0.574-0.760; P < 0.001) and had a significantly superior diagnostic power compared with many other symptoms and signs.

CONCLUSIONS

Our study shows that bendopnea predicts right ventricular energy failure in patients with pulmonary hypertension and can be added to our physical examination armamentarium as an easy, rapid, and noninvasive prognostic tool.

Determinants of Severe Nocturnal Hypoxemia in Adults with Chronic Thromboembolic Pulmonary Hypertension and Sleep-Related Breathing Disorders

OBJECTIVES

We aimed to investigate the occurrence of sleep-related breathing disorders (SRBDs) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and addressed the effect of pulmonary hemodynamics and SRBD indices on the severity of nocturnal hypoxemia (NH).

METHODS

An overnight polysomnography (PSG) was conducted in patients with CTEPH, who were eligible for pulmonary endarterectomy. Pulmonary hemodynamics (mean pulmonary arterial pressure (mPAP), pulmonary arterial wedge pressure (PAWP), pulmonary vascular resistance (PVR) measured with right heart catheterization (RHC)), PSG variables (apnea-hypopnea index (AHI)), lung function and carbon monoxide diffusion capacity (DLCO) values, as well as demographics and comorbidities were entered into a logistic regression model to address the determinants of severe NH (nocturnal oxyhemoglobin saturation (SpO₂) < 90% under >20% of total sleep time (TST)). SRBDs were defined as obstructive sleep apnea (OSA; as an AHI ≥ 15 events/h), central sleep apnea with Cheyne-Stokes respiration (CSA-CSR; CSR pattern ≥ 50% of TST), obesity hypoventilation syndrome (OHS), and isolated sleep-related hypoxemia (ISRH; SpO₂ < 88% under >5 min without OSA, CSA, or OHS).

RESULTS

In all, 50 consecutive patients (34 men and 16 women; mean age 54.0 (SD 15.1) years) were included. The average mPAP was 43.8 (SD 16.8) mmHg. SRBD was observed in 40 (80%) patients, of whom 27 had OSA, 2 CSA-CSR, and 11 ISRH. None had OHS. Severe NH was observed in 31 (62%) patients. Among the variables tested, age (odds ratio (OR) 1.08, 95% confidence interval [CI] 1.01-1.15; p = 0.031), mPAP (OR 1.11 [95% CI 1.02-1.12; p = 0.012]), and AHI (OR 1.17 [95% CI 1.02-1.35; p = 0.031]) were independent determinants of severe NH.

CONCLUSIONS

Severe NH is highly prevalent in patients with CTEPH. Early screening for SRBDs and intervention with nocturnal supplemental oxygen and/or positive airway pressure as well as pulmonary endarterectomy may reduce adverse outcomes in patients with CTEPH.

Results of surgical treatment of pulmonary artery sarcomas: Does histology affect survival?

Background

In this study, we aimed to describe our experience with primary pulmonary artery sarcoma in patients who underwent pulmonary endarterectomy and to evaluate clinical features, treatment, outcomes, and survival rates according to the histological subtypes of this malignant disease.

Methods

Between March 2011 and May 2022, a total of 13 patients (7 males, 6 females; mean age: 52.6±13.0 years; range, 30 to 69 years) who underwent pulmonary endarterectomy and diagnosed with a pulmonary artery sarcoma were retrospectively analyzed. The diagnosis was confirmed histopathologically in all patients. Data including demographics, clinical characteristics, intra- and postoperative complications, length of hospital stay, morbidity, mortality, and short-term and long-term outcomes were recorded. Operative mortality was defined as death in the hospital or within 30 days of surgery.

Results

Mortality was observed in one patient due to massive hemoptysis. Morbidity developed in two patients due to acute respiratory distress. Pulmonary vascular resistance improved significantly from 508 dyn/s/cm-5 to 191 dyn/s/cm-5 (p<0.004). All patients received chemotherapy following surgery. Median followup was 14 months. Median survival for the entire series was 18 months. One-year and three-year survival rates were 60.6% and 30.3%, respectively. Median survival for leiomyosarcomas (n=6) was seven months, while it was 44 months for intimal sarcomas (p=0.004). Three-year survival was 66.7% for intimal sarcomas and 0% for leiomyosarcomas.

Conclusion

Pulmonary artery sarcoma may mimic chronic thromboembolic pulmonary hypertension. Patients with a suspected diagnosis of pulmonary artery sarcoma should be referred to expert pulmonary endarterectomy centers for surgery where a multidisciplinary team is available. Pulmonary endarterectomy has both diagnostic and therapeutic value and may improve survival and quality of life. Patients with intimal sarcoma have longer survival compared to those with leiomyosarcoma.

Are Guideline-recommended Risk Classification Schemes in Pulmonary Hypertension Adequately Robust to Guide the Real-world Setting?

Background

Pulmonary hypertension is a complex syndrome that encompasses a diverse group of pathophysiologies predisposed by different environmental and genetic factors. It is not clear to which extent the universal risk classification schemes can be applied to cohorts in individual pulmonary hypertension centers with differing environmental backgrounds, genetic pools, referral networks.

Aims

We sought to explore whether the recommended risk classification schemes could reliably be used for mortality prediction in an unselected pulmonary hypertension population of a tertiary pulmonary hypertension center.

Study Design

A retrospective cross-sectional study.

Methods

We retrospectively screened our hospital database for the patients with pulmonary hypertension between 2015 and 2022. We compared the predicted and observed mortality rates of several risk classifications schemes.

Results

We identified 723 cases in our PH database, the final study population consisted of 549 patients. The REVEAL, REVEAL-Lite and European Society of Cardiology/European Respiratory Society risk scores significantly underestimated the mortality risk in the low-risk stratum (5.3% vs. 1.9%, P < 0.001; 5.3% vs. 2.9%, P = 0.015 and 6.3% vs. 1%, P < 0.001, respectively) and overestimated the mortality risk in the high-risk stratum (11.8% vs. 25.8%, P < 0.001; 10.4% vs. 25.1%, P < 0.001 and 13.2% vs. 30%, P < 0.001, respectively). Although the COMPERA 4-strata model significantly underestimated the risk in low- and intermediate-low risk strata (4.9% vs. 1.5%, P < 0.001 and 6.8% vs. 2.8%, P = 0.001, respectively), it was accurate in intermediate-high and high-risk groups (10.1% vs. 8.7%, P = 0.592 and 15.6% vs. 22%, P = 0.384, respectively). The analyses limited only to group 1 pulmonary hypertension patients gave similar results.

Conclusion

The established risk classification schemes may not perform as good as expected in unselected PH populations and this may have important implications on management decisions. Tertiary centers should not uncritically accept the published risk prediction models and consider modifying current risk scores according to their own patient characteristics.

Extracellular Matrix Collagen Biomarker Levels in Patients who Underwent Pulmonary Endarterectomy

OBJECTIVE

The role of extracellular matrix collagen biomarkers in chronic thromboembolic pulmonary hypertension is not well known. Our aim is to investigate the matrix metalloproteinase-2 and -9 protein levels in patients with chronic thromboembolic pulmonary hypertension.

MATERIALS AND METHODS

This is a prospective and cross-sectional study. Patients with chronic thromboembolic pulmonary hypertension who underwent pulmonary endarterectomy (Group 1) and the control group included patients who underwent lung surgery without pulmonary hypertension (Group 2) between March 2020 and March 2021. In addition to serum levels of matrix metalloproteinase-9, the pulmonary endarterectomy and control pulmonary artery tissue samples were measured by ELISA 4pl, cubic, quadratic and western blot techniques. Levels of matrix metalloproteinase-2 which consist of pro matrix metalloproteinase-2/ß-actin and active matrix metalloproteinase-2/ß-actin and matrix metalloproteinase-9/ß-actin were measured only in the tissue samples.

RESULTS

Forty eight patients were enrolled consecutively in Group 1 (n: 24) and Group 2 (n: 24). The serum concentrations of matrix metalloproteinase-9 were similar in both groups. Similarly, in comparison of tissue sample levels of pro matrix metalloproteinase-2/ß-actin (p: 0.496) and active matrix metalloproteinase-2/ß-actin (p: 0.216) no significant difference was found between the groups. Chronic thromboembolic pulmonary hypertension patients had significantly lower tissue samples of matrix metalloproteinase-9/ß-actin compared to the control group (p: 0.001).

CONCLUSION

This study indicates that serum levels of extracellular matrix collagen biomarkers were similar in patients with chronic thromboembolic pulmonary hypertension who candidates for surgery and non-pulmonary hypertension patients are who undergo lung surgery. Differences in levels of matrix metalloproteinase-9/ß-actin in tissue samples may play a role in pulmonary vascular remodeling in operable patients.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04773028.

Right Ventricular Energy Failure Predicts Mortality in Patients With Pulmonary Hypertension

Right ventricular (RV) failure has a significant adverse impact on pulmonary hypertension (PH) prognosis. None of the currently used parameters directly assess whether RV fails to provide enough energy output to propel the blood through diseased pulmonary vascular system. Furthermore, most of the current parameters are affected by the volume status of the patient. We aimed to explore whether RV energy failure has a predictive power for mortality on top of the established prognostic risk parameters in patients with PH. We screened 723 cases from our database. A total of 3 sets of binary regression analyses were executed to determine the hazard ratios (HRs) of RV energy failure for 5-year mortality in clinical, echocardiographic, and hemodynamic context, using adjustment variables chosen according to previous studies. The final study population encompassed 549 cases. A total of 77 patients died during the 5-year follow-up (14%). RV energy failure was observed in 146 of 549 patients (26.6%). In the univariate model, RV energy failure strongly associated with increased long-term mortality (HR 4.25, 95% confidence interval [CI] 2.58 to 7.00, p <0.001). It also emerged as a significant predictor of long-term mortality in clinical and hemodynamic multivariate models (HR 2.59, 95% CI 1.43 to 4.67, p = 0.002 and HR 2.05, 95% CI 1.15 to 3.63, p = 0.015, respectively). In conclusion, our study indicates that the presence of RV energy failure independently predicts long-term mortality in PH.

Intra-aortic Balloon Occlusion for Refractory Cardiac Arrest in a Patient with Anterior Myocardial Infarction

Despite recent advances in its management, the outcome of cardiac arrest is often poor despite appropriate cardiopulmonary resuscitation. The arteriovenous perfusion gradient achieved dur ing cardiopulmonary resuscitation is associated with the successful return of spontaneous cir culation. Continuous balloon occlusion of the descending aorta is an experimental method that can occlude the "unnecessary" part of the circulation, thus diverting generated pressure and blood flow to the heart and brain. In this study, we present a case report of a patient unre sponsive to standard cardiopulmonary resuscitation, in whom constant intra-aortic balloon occlusion achieved a return of spontaneous circulation and successful survival.

Risk assessment in inoperable chronic thromboembolic pulmonary hypertension

Background

Our objective was to investigate an abbreviated version of the the current European PH guidelines, noninvasive French model, an abridged version of the REVEAL 2.0 risk score calculator, REVEAL Lite 2, and a refined 4-strata risk assessment model, COMPERA 2.0 for inoperable chronic thromboembolic pulmonary hypertension (CTEPH).

Methods

We enrolled inoperable CTEPH patients from 8 PAH centers from December 2009 to June 2020 (n=123). 70% of patients were treated with PAH therapies. Noninvasive French model comprising WHO functional class (FC), 6-minute walk distance (6 MWD), and N-terminal pro–brain natriuretic peptide (NT-pro BNP) or BNP was used for 63 patients. REVEAL Lite 2 including FC, systolic blood pressure, heart rate, 6MWD, BNP/NT-pro BNP, and estimated glomerular filtration rate was used for 71 patients. COMPERA 2.0 including FC, 6MWD and BNP/NT-pro BNP was used for 71 patients. Patients were grouped into three categories according to the French model and REVEAL Lite 2 scores, and into four categories according to COMPERA 2.0. Kaplan-Meier (KM) survival was assessed in each risk group with all-cause mortality as the end point. Log-rank test was used to compare estimates.

Results

The mean age was 64±13 years at diagnosis. The median follow-up was 22.7 months. 26 patients had died. None of the patients had balloon pulmonary angioplasty. Most patients had received monotherapy (55%). 23.8% of patients were WHO FC I-II, 65.6% III, and 10.7% IV at initial evaluation (Table 1). All models discriminated risk in our cohort. Patients having none of low-risk criteria or high risk profiles by REVEAL Lite 2 and COMPERA 2.0 at follow-up had the worst survival. Figure 1 demonstrates KM survival curves for noninvasive French model (A), REVEAL Lite 2 (B), and COMPERA 2.0 (C). 37.3% of patients achieved 2 or more low risk criteria at follow-up. 44.8% of patients were in low risk at follow-up (REVEAL lite 2). 52.1% of patients were in low and intermediate-low risk at follow-up (COMPERA 2.0). The estimated survival rate at 5 years of patients meeting 2 and more low-risk criteria was 86% vs. 55% for patients meeting 0 low-risk criterion (p=0.04). The corresponding survival rate was 45% for high-risk patient, 79% for intermediate-risk patient, and 82% for low-risk patient (REVEAL lite 2) (p=0.029). The corresponding survival rates were 51.1% for high-risk patient and 91.6% for intermediate-low risk patient (COMPERA 2.0) (p=0.017). COMPERA 2.0 seems more accurate based on c-index. Survival was similar between patients treated and not treated with PAH therapies (p=0.735).

Conclusions

Noninvasive French model, REVEAL Lite 2, and COMPERA 2.0 may provide a simplified method of risk assessment for inoperable CTEPH. This analysis also supports the value of goal-oriented treatment in CTEPH. Patients who have not achieved low risk category at follow-up may benefit from escalation of their treatment regimen.

Funding Acknowledgement

Type of funding sources: None.

Change in pulmonary arterial compliance and pulmonary pulsatile stress after balloon pulmonary angioplasty

OBJECTIVE

Although the underlying pathology of chronic thromboembolic pulmonary hypertension (CTEPH) is mechanical obliteration of the major pulmonary vessels, high pulsatile stress penetrating into the normal distal pulmonary microvasculature resulting from reduced pulmonary arterial compliance (CPA) may cause progressive deterioration in pulmonary hemodynamics. Hypothetically, balloon pulmonary angioplasty (BPA) may be beneficial in reducing CPA and pulsatile stress in patients with CTEPH.

METHODS

In total, 26 patients with available pre- and post-BPA right heart catheterization results were included in the study. BPA was performed in a series of staged procedures by 2 experienced interventional cardiologists.

RESULTS

The median CPA showed a 59.2% increase (1.03 to 1.64 mL/mm Hg, p=0.005). The median pre-BPA pulsatile stress product decreased by 20.7% (4,266 to 3,380 mm Hg/min, p=0.003). A linear regression model established that the percent change in CPA after BPA accounted for 21.8% of the explained variability in the change in 6-minute walk test (p=0.009).

CONCLUSION

Our results indicate that BPA decreases CPA and pulmonary pulsatile stress. These changes may be partly responsible for the improvement in functional capacity after BPA.

Pulmonary Endarterectomy in Patients with Antiphospholipid Syndrome-Associated Chronic Thromboembolic Pulmonary Hypertension

Background

Antiphospholipid syndrome is an autoimmune disease characterized by the occurrence of venous and/or arterial thrombosis. Chronic thromboembolism is one of the known established pathogenesis of pulmonary hypertension, known as chronic thromboembolic pulmonary hypertension. Pulmonary endarterectomy is the treatment of choice for chronic thromboembolic pulmonary hypertension. The aim of this study is to evaluate the efficacy and risk of pulmonary endarterectomy in patients with antiphospholipid syndrome-associated chronic thromboembolic pulmonary hypertension.

Methods

Data were prospectively collected and retrospectively analyzed, for patients who underwent pulmonary endarterectomy between March 2011 and March 2020.

Results

Seventeen patients (4 male and 13 female) were identified. Thirteen patients had primary antiphospholipid syndrome and 4 had secondary antiphospholipid syndrome. The mean age was 34.82 ± 10.07 years and the mean time interval between the diagnosis and surgery was 26.94 ± 17.35 months. Dyspnea on exertion was the main symptom in all patients. Seven patients had previous deep vein thrombosis, 5 patients had a history of recurrent abortions, and 2 patients had hemoptysis. Following surgery, mean pulmonary artery pressure decreased from 47.82 ± 13.11 mm Hg to 22.24 ± 4.56 mm Hg (P < .001), and pulmonary vascular resistance improved from 756.50 ± 393.91 dyn/s/cm⁻⁵ to 298.31 ± 132.84 dyn/s/cm⁻⁵ (P < .001). There was no in-hospital mortality with a mean follow-up of 75.29 ± 40.21 months. The functional capacity of all patients improved from 269.46 ± 111.7 m to 490 ± 105.34 m on a 6-minute walking test.

Conclusions

Pulmonary endarterectomy is a safe and curative treatment in patients with antiphospholipid syndrome-associated chronic thromboembolic pulmonary hypertension. It has a favorable outcome by increasing the quality of life. A multidisciplinary experienced chronic thromboembolic pulmonary hypertension team is critical in the management of these unique patients.

Evaluation of Asymmetric Dimethylarginine Levels in Patients With Chronic Thromboembolic Pulmonary Hypertension Undergoing Pulmonary Endarterectomy

BACKGROUND

Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary embolism, and pulmonary endarterectomy (PEA) is the surgical treatment. Asymmetric dimethylarginine (ADMA) levels are increased in pulmonary hypertension. This study aimed to investigate serum ADMA levels in patients with CTEPH, the effect of PEA on ADMA, and its prognostic value in long-term mortality.

METHOD

Eighty (80) patients with CTEPH and 32 healthy controls were included. Preoperative serum ADMA levels, determined using an enzyme-linked immunosorbent assay, were compared between patients with CTEPH and controls. Of 80 patients, 64 had PEA. Pre- and 6-month postoperative serum ADMA levels, 6-minute walk distance (6MWD), and haemodynamic parameters were collected from patients undergoing PEA. Patients were followed-up for survival analysis.

RESULTS

Mean ± standard deviation serum ADMA levels were significantly higher in patients with CTEPH compared with controls (0.79±0.32 μmol/L vs 0.52±0.12 μmol/L; p=0.0001). Statistically significant differences were observed between preoperative and postoperative serum ADMA levels (0.78±0.30 μmol/L vs 0.62±0.22 μmol/L; p=0.0001), 6MWD (p=0.0001), and pulmonary vascular resistance (p=0.0001) in 60 patients who underwent and survived PEA. The decrease in serum ADMA levels and increase in 6MWD were significantly correlated (r=-0.286, p=0.027). No other correlation was found. Perioperative mortality was 6.3%, and the survival rate with a mean follow-up of 34.57±8.20 months was 93.3%. Patients with serum ADMA levels >0.8 μmol/L had a significantly lower survival rate (logrank: 5.86; p=0.015).

CONCLUSIONS

Levels of circulating ADMA might add diagnostic and prognostic information in CTEPH. Pulmonary endarterectomy is associated with an improvement in serum ADMA levels. Preoperative serum ADMA levels may be useful for estimating the outcome of PEA.

Correlation Between Perfusion Abnormalities Extent in Ventilation/Perfusion SPECT/CT with Hemodynamic Parameters in Patients with Chronic Thromboembolic Pulmonary Hypertension

Objectives

Chronic thromboembolic pulmonary hypertension (CTEPH) is a type of pulmonary hypertension with persistent pulmonary vascular obstruction and exercise intolerance, which may benefit from pulmonary endarterectomy (PEA). Ventilation/perfusion (V/Q) scan is the preferred screening test of CTEPH, which can be used to assess the anatomical extent of the disease. This study aimed to analyze the correlation between the extent of mismatched Q defects in V/Q single photon emission computed tomography/computed tomography (SPECT/CT) with preoperative clinical and hemodynamic parameters in patients with CTEPH.

Methods

A total of 102 patients with CTEPH prior to PEA having V/Q SPECT/CT scans were retrospectively reviewed. Age, gender, New York Heart Association classification, intraoperative right-sided heart catheterization (mPAP and PVR), and 6-minute walk test (6MWT) findings were obtained from clinical records of patients.

Results

Linear regression analysis showed a significant but weak correlation between the preoperative mPAP and PVR with the extent of mismatched Q defects in V/Q SPECT/CT (rs=0.09474 with p=0.0016 and rs=0.045 with p=0.045, respectively). No significant correlation was found between 6MWT and extent of mismatched Q defects in V/Q SPECT/CT (p>0.05).

Conclusion

A quantitative assessment of Q defects on V/Q SPECT/CT might provide information about hemodynamic parameters in patients with CTEPH.

Caregiver Burden in Patients with Pulmonary Hypertension

Both quality of life (QoL) and caregiver burden are essential constructs in patients with pulmonary hypertension (PH) however; their relationship has never been investigated before. The aim of this study was to evaluate if there was any relationship between patients' QoL and caregiver burden. Patients with PH and their caregivers were included. Patients' age, sex, World Health Organization (WHO) functional class, systolic pulmonary arterial pressure (sPAP), and six-minute walk distances (6MWD) were recorded. Patients' QoL was assessed using emPHasis-10 and caregiver burden with the Zarit Caregiver Burden Scale. 72 patient-caregiver dyads were included. Caregiver burden was significantly correlated with the QoL(r = 0.39 p < .003), but was not correlated with other clinical parameters. Patients' QoL showed significant negative correlation with the 6MWD(r = -0.46 p < .005). There is a moderate correlation between QoL and caregiver burden. Clinical parameters influence QoL, but they do not affect caregiver burden.

Age-related characteristics of infective endocarditis: prospective data from the Euro-Endo registry

Introduction

The profile of infective endocarditis (IE) is continuously evolving over time, and this may probably be partly due to increasing age of the patients.

Methods

All data were collected from the EURO-ENDO registry, which is a one-year prospective international multicentre observational survey on patients with definite or possible IE included between 2016 and 2018. Subjects were stratified into 3 groups according to their age at index hospitalization.

Results

Among the 3113 patients included, 1670 patients (54%, Young group) were &lt;65, 1068 (34%, Medium group) between 65 and 80 and 375 (12%, Old group) ≥80 years old. The most striking age-related differences were (old group vs others) (table 1) 1) the higher comorbidity burden and Charlson index; 2) the lower rate of embolic events on admission and under therapy; 3) the higher rate of Enterocci and digestive streptococci; 4) the lower rate of surgery during acute IE despite a theoretical indication; 5) the higher in-hospital and 1-year mortality. With regards to surgery, young and medium age were predictive of more frequent performance of surgery as compared to old age (Young: OR 4.33, 95% CI [3.09–6.06], Medium: 3.62, [2.57–5.10], p&lt;0.001). In multivariable analysis, age per se was not predictive of in-hospital and 1yr FU mortality, but lack of surgical procedures when indicated (27% of the old group), was strongly predictive.

Conclusion

This is the largest contemporary registry showing the strong influence of age on the demographic, clinical, therapeutic, and prognostic profile of IE. Non-performance of surgical procedures when indicated is frequent in old patients and is a strong predictor of mortality while age per se is not. Endocarditis Teams should take these results into account when considering surgery in elderly patients.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): EORP grant

A case of heart failure mimicking COVID-19 pneumonia: The role of clinical and chest computed tomography findings in the differential diagnosis

Acute heart failure (HF) is one of the most common cardiac emergencies. Pulmonary edema caused by HF may mimic an exudative disease on chest computed tomography scans. Coronavirus disease 2019 (COVID-19) emerged in China in December 2019 and quickly spread around the world. During this pandemic period, the need to exclude the possibility of COVID-19 pneumonia in patients with acute dyspnea may cause a delay in the diagnosis and treatment of patients with acutely decompensated HF who have similar symptoms. This case report describes a diabetic patient admitted with dyspnea one week after she suffered an acute myocardial infarction. The objective of this report is to draw attention to the differential diagnosis of HF and COVID-19 pneumonia.

[Turkish Cardiology Association Consensus Report: COVID-19 Pandemic and Cardiovascular Diseases (May 13, 2020)]

In December 2019, in the city of Wuhan, in the Hubei province of China, treatment-resistant cases of pneumonia emerged and spread rapidly for reasons unknown. A new strain of coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) was identified and caused the first pandemic of the 21st century. The virus was officially detected in our country on March 11, 2020, and the number of cases increased rapidly; the virus was isolated in 670 patients within 10 days. The rapid increase in the number of patients has required our physicians to learn to protect both the public and themselves when treating patients with this highly infectious disease. The group most affected by the outbreak and with the highest mortality rate is elderly patients with known cardiovascular disease. Therefore, it is necessary for cardiology specialists to take an active role in combating the epidemic. The aim of this article is to make a brief assessment of current information regarding the management of cardiovascular patients affected by COVID-19 and to provide practical suggestions to cardiology specialists about problems and questions they have frequently encountered.

[Consensus Report from Turkish Society of Cardiology: COVID-19 and Cardiovascular Diseases. What cardiologists should know. (25th March 2020)]

In December 2019, in the city of Wuhan, in the Hubei province of China, treatment-resistant cases of pneumonia emerged and spread rapidly for reasons unknown. A new strain of coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) was identified and caused the first pandemic of the 21st century. The virus was officially detected in our country on March 11, 2020, and the number of cases increased rapidly; the virus was isolated in 670 patients within 10 days. The rapid increase in the number of patients has required our physicians to learn to protect both the public and themselves when treating patients with this highly infectious disease. The group most affected by the outbreak and with the highest mortality rate is elderly patients with known cardiovascular disease. Therefore, it is necessary for cardiology specialists to take an active role in combating the epidemic. The aim of this article is to make a brief assessment of current information regarding the management of cardiovascular patients affected by COVID-19 and to provide practical suggestions to cardiology specialists about problems and questions they have frequently encountered.

NT-proBNP level in stage 3-4 chronic kidney disease and mortality in long-term follow-up: HAPPY study subgroup analysis

OBJECTIVE

This was an investigation of the relationship between the N-terminal pro-brain natriuretic peptide (NT-proBNP) level and mortality in patients with stage 3-4 chronic kidney disease (CKD).

METHODS

This study was designed as a subgroup analysis of the Heart Failure Prevalence and Predictors in Turkey (HAPPY) study. The HAPPY study included 4650 randomly selected individuals from the 7 geographical regions of Turkey. A total of 191 subjects from the original cohort with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.1.73 m² were enrolled in this study and the relationship between NT-proBNP and mortality was investigated. Prognostic variables for total and cardiovascular mortality were also examined using Cox regression analysis.

RESULTS

The mean length of follow-up was 76.12±22.45 months. The mean NT-proBNP level was 423.54±955.88 pg/mL. During follow-up, 51 subjects (26.7%) died from any cause and 36 subjects (18.8%) died from a cardiovascular cause. The presence of hypertension (hazard ratio [HR]: 1.89; 95% confidence interval [CI]: 1.01-3.50; p=0.048), anemia (HR: 2.49; 95% CI: 1.20-5.15; p=0.014), male gender (HR: 2.64; 95% CI: 1.44-4.86; p=0.002) and log NT-proBNP (HR: 4.93; 95% CI: 2.83-8.58; p<0.001) were independent variables for total mortality. The presence of hypertension (HR: 2.47; 95% CI: 1.09-5.56; p=0.029), male gender (HR: 2.79; 95% CI: 1.38-5.62; p=0.004), eGFR (HR: 0.94; 95% CI: 0.91-0.98; p=0.005) and log NT-proBNP (HR: 6.31; 95% CI: 3.11-12.81; p<0.001) were independent predictors of cardiovascular mortality.

CONCLUSION

NT-proBNP was found to be an independent prognostic marker in patients with stage 3-4 CKD.

Improvements of right ventricular function and hemodynamics after balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension

PURPOSE

Right ventricular (RV) function is an important factor in the prognosis of chronic thromboembolic pulmonary hypertension (CTEPH) in patients. In our study, we aimed to evaluate the timing and magnitude of regional RV function before and after balloon pulmonary angioplasty (BPA) using speckle tracking echocardiography (STE) and their relation to clinical and hemodynamic parameters in patients with CTEPH.

MATERIAL AND METHOD

We enrolled 20 CTEPH patients and 19 healthy subjects in our study. Enrolled patients underwent echocardiography, right heart catheterization (RHC), and 6-minute walk distance (6MWD) test at baseline and after the BPA.

RESULTS

In hemodynamic RHC measurements and clinical evaluations, mean pulmonary artery pressure (median: 53.5 mm Hg vs 37.0 mm Hg, P = .001) and pulmonary vascular resistance (median: 12 Wood units [WU] vs 7 WU, P = .001) and pro-brain natriuretic peptide level decreased and 6MWD increased after BPA sessions. There was no statistically significant difference between before and after the BPA sessions in conventional echocardiographic measurements. In STE analysis, the electromechanical delay (EMD) between RV free wall (RVF) and LV lateral wall (LVL) (median: 65 ms vs 47.5 ms, P = .01) and RV peak systolic strain dispersion index (52 ms vs 29 ms, P = .001) were higher in patients with CTEPH than healthy controls before the BPA. Both these parameters decreased significantly after BPA.

CONCLUSION

Chronic thromboembolic pulmonary hypertension was associated with RV electromechanical delay and dispersion based on the STE analysis. Balloon pulmonary angioplasty might have an important impact on the improvement of both RV function and hemodynamics.

Assessment of right ventricular function and relation to mortality after acute pulmonary embolism: A speckle tracking echocardiography-based study

PURPOSE

Right ventricular (RV) dysfunction is a common condition that is related to increased adverse outcomes in patients with acute pulmonary embolism (APE). Our aim was to assess timing and magnitude of regional RV function using speckle tracking echocardiography (STE) and to evaluate their relationship to long-term mortality in patients after APE.

METHODS

In total, 147 patients were enrolled at the onset of an APE episode and followed for 12 ± 1.1 months. For all patients, the clinical, laboratory, and echocardiography examinations were performed at the diagnosis of APE and at the end of the 1-year follow-up.

RESULTS

Of the 147 patients, 44 (29.9%) died during the 1-year follow-up after APE. The patients who died had lower RV free wall peak longitudinal systolic strains (PLSS) and left ventricular (LV) PLSS and higher RV peak systolic strain dispersion (PSSD) index which means the electromechanical dispersion when compared with the survivors. The difference in time to PLSS between the RV free wall and LV lateral wall (RVF-LVL) which means the electromechanical delay was longer in patients who died than in those who survived during follow-up, and this difference was an independent predictor of mortality at 1 year of follow-up after APE, with 86.4% sensitivity and 81.7% specificity. At the end of 1-year follow-up, the RV free wall PLSS and the LV global PLSS increased, whereas the RV PSSD index and the difference in time to PLSS between the RVF and LVL decreased.

CONCLUSIONS

Acute pulmonary embolism was associated with RV dysfunction and RV electromechanical delay and dispersion. These parameters improved at the end of 1-year follow-up. The electromechanical delay index might be a useful predictor of mortality in patients after APE.

Impaired theory of mind in adults with traumatic brain injury: A replication and extension of findings

OBJECTIVE

To replicate a previous study of Theory of Mind (ToM) task performance in adults with traumatic brain injury (TBI) under different working memory (WM) demands, and determine if there are sex-based differences in effects of WM load on ToM task performance.

METHOD

58 adults with moderate-severe TBI (24 females) and 66 uninjured adults (34 females) matched group-wise for age, sex, and education viewed a series of video vignettes from the Video Social Inference Task (VSIT) (Turkstra, 2008) and answered ToM questions. Vignette presentation format required updating and maintenance of information, and WM load was manipulated by varying presence of distracters.

RESULTS

There were main effects of group and WM load, no significant effect of sex, and a marginal interaction of group by WM load, with larger between-group differences in conditions with higher WM load. VSIT scores for the condition with the highest WM load were significantly correlated with scores on the first trial of the California Verbal Learning Test.

CONCLUSIONS

We replicated findings of lower scores in adults with TBI on a video-based ToM task, and provided additional evidence of the effect of WM load on social cognition task performance. There were no significant accuracy differences between men and women, inconsistent with prior evidence - including our own data using the same test. There is strong evidence of a female advantage on other social cognition tasks, and the parameters of this advantage remain to be discovered.

Preliminary results from a nationwide adult cardiology perspective for pulmonary hypertension: RegiStry on clInical outcoMe and sUrvival in pulmonaRy hypertension Groups (SIMURG)

OBJECTIVE

The present study was designed to evaluate the characteristics of pulmonary hypertension (PH) and adult cardiology practice patterns for PH in our country.

METHODS

We evaluated preliminary survey data of 1501 patients with PH (females, 69%; age, 44.8±5.45) from 20 adult cardiology centers (AdCCs).

RESULTS

The average experience of AdCCs in diagnosing and treating patients with PH was 8.5±3.7 years. Pulmonary arterial hypertension (PAH) was the most frequent group (69%) followed by group 4 PH (19%), group 3 PH (8%), and combined pre- and post-capillary PH (4%). PAH associated with congenital heart disease (APAH-CHD) was the most frequent subgroup (47%) of PAH. Most of the patients' functional class (FC) at the time of diagnosis was III. The right heart catheterization (RHC) rate was 11.9±11.6 per month. Most frequently used vasoreactivity agent was intravenous adenosine (60%). All patients under targeted treatments were periodically for FC, six-minute walking test, and echo measures at 3-month intervals. AdCCs repeated RHC in case of clinical worsening (CW). The annual rate of hospitalization was 14.9±19.5. In-hospital use of intravenous iloprost reported from 16 AdCCs in CWs. Bosentan and ambrisentan, as monotreatment or combination treatment (CT), were noted in 845 and 28 patients, respectively, and inhaled iloprost, subcutaneous treprostinil, and intravenous epoprostenol were noted in 283, 30, and four patients, respectively. Bosentan was the first agent used for CT in all AdCCs and iloprost was the second. Routine use of antiaggregant, anticoagulant, and pneumococcal and influenza prophylaxis were restricted in only two AdCCs.

CONCLUSION

Our nationwide data illustrate the current status of PH regarding clinical characteristics and practice patterns.

Outcomes of Patients with Behçet's Syndrome after Pulmonary Endarterectomy

Background Behçet's syndrome (BS) is a multisystem disorder and is not known as a risk factor for chronic thromboembolic pulmonary hypertension (CTEPH), for which the treatment of choice is pulmonary endarterectomy (PEA). The aim of this study was to review our experience in the surgical treatment of CTEPH in patients with BS.

Methods Data were collected prospectively for consecutive patients with BS who underwent PEA over a 6-year period.

Results We identified nine patients (seven males, two females, mean age: 34.7 ± 9.9 years) with BS. The mean disease duration before PEA was 88.0 ± 70.2 months. All patients but one received immunosuppressive therapy before the surgery. Exercise-induced dyspnea presented symptoms in six patients. One patient had associated intracardiac thrombosis. PEA was bilateral in five patients, unilateral in three, and lobar in one. No perioperative mortality was observed; however, one patient died four weeks after PEA due to massive hemoptysis. Morbidity was observed in two patients. The systolic pulmonary artery pressure fell significantly from 59.0 ± 22.7 mm Hg to 30.0 ± 6.5 mm Hg after surgery (p = 0.031). Pulmonary vascular resistance also improved significantly from 611.8 ± 300.2 to 234.7 ± 94.9 dyn/s/cm5 (p = 0.031). After a median follow-up of 29.4 months, all patients improved to the New York Heart Association (NYHA) functional class I and II.

Conclusion Patients with BS may suffer recurrent pulmonary embolism and develop CTEPH. In patients who do not respond to anticoagulation or immunosuppressive therapy, PEA may be a therapeutic option when thrombotic lesions are surgically accessible. Due to the high risk of perioperative mortality, the procedure should be undertaken in centers with experience.

[Effect of pulmonary endarterectomy on six-minute walking test and echocardiography in the early stage]

OBJECTIVE

Pre- and postoperative changes in echocardiographic parameters and results of 6-minute walking test (6-MWT) were investigated in the present study.

METHODS

Seventy-six patients (32 males, 44 females; mean age 45.9±15.1 years) were included. Before and after surgery, 6-MWT and echocardiography were performed. Changes in postoperative parameters were compared to basal walking test and other basal parameters.

RESULTS

Distance covered in 6-MWT significantly increased after surgery (p<0.001). Significant decrease in right ventricular diameter and pressure, and significant increase in left ventricular diameter were also observed. While changes in ejection fraction (EF) were not significant, significant reduction in systolic pulmonary artery pressure (sPAP) and tricuspid regurgitation were observed. No statistically significant correlation was observed between baseline 6-MWT results and echocardiographic parameters.

CONCLUSION

The present study was the first to investigate the correlation between baseline 6-MWT results and right ventricular echocardiographic parameters. Myocardial performance index (MPI) and TAPSE were important parameters in follow-up after pulmonary endarterectomy. Improvement in quality of life parameters was also important.

Predictors and Prognostic Significance of Troponin-I Release following Elective Coronary Angioplasty

The objective of this study was to investigate the predictors and prognostic significance of post-procedural cardiac troponin (cTn)-I elevations in a consecutive series of patients who underwent elective percutaneous coronary intervention (PCI). cTn-I was measured in 100 patients immediately before and within 24 h after the elective PCI. Post-procedural cTn-I elevation was observed in 27 of the 100 patients. In multivariate analysis, basal haemoglobin values and the number of repeated balloon dilatations were found to be independent predictors of cTn-I elevation. During the follow-up period of 12 ± 1.2 months, the cTn-I-positive group had more major adverse cardiovascular events than the cTn-I-negative group (33.3% versus 16.4%, respectively), but the difference was not significant. An increase in cTn-I levels following elective PCI procedures was frequent but did not predict a poor long-term outcome.

The features of infectious diseases departments and anti-infective practices in France and Turkey: a cross-sectional study

The aim of this study was to assess the infectious diseases (ID) wards of tertiary hospitals in France and Turkey for technical capacity, infection control, characteristics of patients, infections, infecting organisms, and therapeutic approaches. This cross-sectional study was carried out on a single day on one of the weekdays of June 17-21, 2013. Overall, 36 ID departments from Turkey (n = 21) and France (n = 15) were involved. On the study day, 273 patients were hospitalized in Turkish and 324 patients were followed in French ID departments. The numbers of patients and beds in the hospitals, and presence of an intensive care unit (ICU) room in the ID ward was not different in both France and Turkey. Bed occupancy in the ID ward, single rooms, and negative pressure rooms were significantly higher in France. The presence of a laboratory inside the ID ward was more common in Turkish ID wards. The configuration of infection control committees, and their qualifications and surveillance types were quite similar in both countries. Although differences existed based on epidemiology, the distribution of infections were uniform on both sides. In Turkey, anti-Gram-positive agents, carbapenems, and tigecycline, and in France, cephalosporins, penicillins, aminoglycosides, and metronidazole were more frequently preferred. Enteric Gram-negatives and hepatitis B and C were more frequent in Turkey, while human immunodeficiency virus (HIV) and streptococci were more common in France (p < 0.05 for all significances). Various differences and similarities existed in France and Turkey in the ID wards. However, the current scene is that ID are managed with high standards in both countries.

Left ventricular strain and strain rate by two-dimensional speckle tracking echocardiography in patients with subclinical hypothyroidism

AIM

Subclinical hypothyroidism (SH) is an asymptomatic condition defined by increased serum thyroid-stimulating hormone (TSH) with normal free thyroid hormone levels. Heart is a major target organ for thyroid hormone action. The aim of this study was to evaluate cardiac functions in patients with SH by speckle tracking imaging.

PATIENTS AND METHODS

We included 23 consecutive patients with untreated SH (Group A; 7 male, mean age: 40.9±1.6 years) and 21 patients with treated SH (Group B; 6 male, mean age: 40.2±2.1 years). The control group included 25 healthy volunteers (8 male, mean age: 39.9±2.8 years). Left ventricular (LV) functions were assessed with speckle tracking imaging.

RESULTS

Age and sex distributions were similar among the groups. Mean serum TSH and free T4 levels were 11.7±2.9 µIU/mL, 1.16±0.06 ng/dL for group A; 2.6±0.3 µIU/mL, 1.35±0.09 ng/dL for group B; 1.4±0.3 µIU/mL, 1.31±0.09 ng/dL for controls, respectively (p = 0.001, p = 0.122). The untreated SH patients had significantly lower LV strain and strain rate values compared to controls. The treated SH patients had higher LV strain and strain rate values compared to untreated SH patients although the difference was not statistically significant. The treated SH patients had lower LV strain and strain rate values compared to controls but the difference was not statistically significant.

CONCLUSIONS

Untreated SH is associated with impairment in LV longitudinal myocardial function. Speckle tracking echocardiography appears to be useful both for early detection of LV impairment in patients with SH and documentation of improvement in myocardial deformation parameters with treatment.

Evaluation of treatment with hydrocortisone on oxidant/antioxidant system in preterm infants with BPD

AIM

Evidence that oxidative stress plays a role in the development of bronchopulmonary dysplasia (BPD). There is a close relationship between oxidative stress and inflammation. In this study, it is aimed to investigate influences of hydrocortisone used in the treatment of BPD on anti-oxidant system in preterm infants with BPD.

PATIENTS AND METHODS

The study enrolled 33 infants with severe BPD who were undergone inpatient treatment in neonatal intensive care unit (NICU) of our Hospital and received therapy with hydrocortisone. Total oxidant status (TOS) and total anti-oxidant capacity (TAC) levels of infants enrolled to the study before and one week after the hydrocortisone therapy were studies and oxidative stress index levels were calculated. Pre- and post-treatment TOS, TAC and OSI index levels were statistically compared.

RESULTS

In preterm infants with BPD, who were enrolled into the study, TOS and OSI index were found high, whereas TAC values were low. Following the treatment with hydrocortisone, statistically significant decrease in TOS and OSI index and statistically significant elevation in TAC levels were found in comparison with pre-treatment levels.

CONCLUSIONS

The treatment with hydrocortisone, which is used for BPD, improves anti-oxidant system and reduces oxidative stress in infants with BPD. There is need for further studies in order to clarify the physio-pathogenesis.

Right ventricular longitudinal deformation parameters and exercise capacity : prognosis of patients with chronic thromboembolic pulmonary hypertension

OBJECTIVE

Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive disease characterized by increased pulmonary vascular resistance resulting in pulmonary hypertension and right heart failure. The six-minute walk test (6MWT) distance is associated with the prognosis of CTEPH patients. Speckle tracking echocardiography (STE) is a reliable method for determining ventricular function. The aim of this study was to assess and compare the right ventricular (RV) function of CTEPH patients according to their 6MWT distances.

METHODS

Forty-nine consecutive CTEPH patients (mean age, 50 ± 16 years; 22 male) who were referred to our center for pulmonary thromboendarterectomy (PTE) were included in the study. All patients underwent the 6MWT and right heart catheterization (RHC). Standard echocardiography and STE were performed on all patients before PTE. Patients were divided into two groups based on their 6MWT distance being less or more than 300 m.

RESULTS

Patients with a shorter 6MWT distance had a significantly larger RV, while they had a significantly lower RV fractional area change and higher myocardial performance index suggesting impaired RV function. Both RV basal-lateral strain and strain rate measures were significantly lower in patients with shorter 6MWT distances than those with longer 6MWT distances. Similarly, they had lower RV basal-septal, mid-lateral, and global strain measures. 6MWT distances were correlated with RV basal-lateral and mid-lateral strain measures (r = 0.349, p = 0.025 and r = 0.415, p = 0.008, respectively).

CONCLUSION

Our data suggest that RV myocardial deformation parameters are associated with 6MWT distances. Determination of RV dysfunction by STE may be helpful in identifying patients with a poor prognosis.