Interest of TAPSE/sPAP ratio for noninvasive pulmonary arterial hypertension risk assessment

BACKGROUND

Although ventriculoarterial coupling is associated with better survival in pulmonary arterial hypertension (PAH), existing PAH risk assessment method has not considered echocardiographic criteria of right ventricular to pulmonary artery coupling. We aimed to test the prognostic value of the echocardiographic tricuspid annular plane systolic excursion/systolic pulmonary artery pressure (TAPSE/sPAP) ratio for noninvasive PAH risk assessment.

METHODS

We retrospectively studied a cohort of 659 incident PAH patients from 4 independent French PH centers (training cohort: n = 306, validation cohort n = 353) who underwent follow-up TAPSE/sPAP measurement in addition to previously validated noninvasive risk stratification variables. The primary composite outcome was 3-year all-cause mortality or lung transplantation from re-evaluation.

RESULTS

Mean age was 55 ± 17 years-old with a majority of female (66%). The three main PAH causes were connective tissue disease (26%), idiopathic (24%) and porto-pulmonary (19%). The primary composite outcome occurred in 71 (23%) patients. Multivariable Cox regression analysis retained 3 noninvasive low-risk criteria as associated with the primary composite outcome: NYHA I-II (p = 0.001), NTproBNP <300 ng/L or BNP <50 ng/L (p = 0.004), and TAPSE/sPAP >0.33 mm/mmHg (p = 0.004). The more the low-risk criteria achieved at follow-up, the better the event-free survival both in the training and validation cohort (log-rank p < 0.001). In the training cohort, the c-index for these 3 criteria, for COMPERA 2.0 and for the noninvasive French Pulmonary Hypertension Network method were 0.75, 95%CI(0.70-0.82), 0.72 95%CI(0.66-0.75), 0.71 95%CI(0.62-0.73), respectively.

CONCLUSION

The 3 following dichotomized low-risk criteria: TAPSE/sPAP >0.33 mm/mmHg, NYHA I-II and NTproBNP <300 ng/L or BNP <50 ng/L allow to identify low-risk PAH patients at follow-up.

Right ventricular improvement is associated with left ventricular diastolic function and size enhancement in PAH patients: an echocardiographic study

Background

While pulmonary vasodilation therapy improves right ventricular (RV) function in pulmonary arterial hypertension (PAH), data regarding left ventricular (LV) function remain sparse.

Purpose

We aimed to investigate whether PAH therapy improve LV function in PAH patients.

Methods

Between 2002 and 2020, all incident PAH patients from one PH referral centers were included, treated and followed-up according to current ESC/ERS guidelines. All patients had comprehensive echocardiography both investigating right and left ventricular function before and after 1-year of vasodilation therapy. In addition to RV echocardiographic evaluation, we focused on LV ejection fraction from Modified Simpson method, LV diameters by M-mode, transmitral pulsed-wave E/A ratio, Flow to tissue Doppler imaging E/e' ratio, and left atrial size.

Results

126 patients were included (63% female, 57±17 yo), mainly from connectivite tissue associated and idiopathic PAH (24% and 28% respectively) causes. Compared to baseline, 1-year NYHA functional class (p&lt;0.01), NTproBNP plasma level (p&lt;0.001), invasive mean pulmonary arterial pressure (p&lt;0.01) and cardiac index (p&lt;0.01) significantly improved. While LV ejection fraction (p=0.68), LV end-diastolic diameter (p=0.11) as well as LA area and volume (p=0.09) were not significantly enhanced under vasodilation therapy, LV diastolic function, assessed by mitral E wave (p&lt;0.01), tissue doppler imaging mitral e' wave (p=0.04), and E/A ratio (p=0.045) were significantly improved at 1-year. There was a significant correlation between LV end-diastolic diameter (p&lt;0.001) and RV end-diastolic area (p&lt;0.001) owing to the normalization of right- to left ventricular interdependence, as well as between mitral E wave and TAPSE (p=0.045).

Conclusion

By improving RV function, PAH vasodilation therapy enhances LV size and diastolic function and normalizes the biventricular interdependence.

Funding Acknowledgement

Type of funding sources: None.

Inclusion of echocardiographic measure of right ventricular function in the non-invasive French pulmonary arterial hypertension risk stratification method

Background

Although preserved right ventricular (RV) function is consistently associated with better survival in pulmonary arterial hypertension (PAH), the French risk assessment method has not yet considered echocardiographic criteria of RV function.

Purpose

In the present study, we tested the value of tricuspid annular plane systolic excursion (TAPSE) measured by echocardiography for non-invasive PAH risk assessment.

Methods

We retrospectively studied a cohort of 306 incident PAH patients treated in two French expert centers who underwent follow-up TAPSE measurement from echocardiographic apical 4-chamber view in addition to previously validated invasive and non-invasive risk stratification variables. The primary composite outcome was 3-year lung transplantation free survival after follow-up assessment.

Results

At re-evaluation, 66% of patients were in NYHA functional class I-II and mean pulmonary arterial pressure, cardiac index, N-Terminal pro brain natriuretic peptide (NTproBNP), and 6-minute walk distance (6MWD) were 40±16 mmHg, 3.5±1.1 L/min/m2, 270 [interquartile range (IQR) 896] ng/L and 401 (IQR 213) meters, respectively. The primary outcome occurred in 58 (19%) patients. In multivariable Cox regression analysis, NYHA functional class I-II (p=0.02), NTproBNP &lt;300 ng/L or BNP &lt;50 ng/L (p=0.02), 6MWD &gt;440m (p=0.049) and TAPSE≥17 mm (p=0.02) were associated with lung transplantation free survival. TAPSE provided similar information over 6MWD when both were used alternatively to stratify PAH patients at low risk (log-rank&lt;0.001); Harrell's c-index 0.73.

Conclusion

Three dichotomized low-risk criteria (TAPSE, 6MWD and NTproBNP or BNP plasma levels) allow non-invasive risk assessment in PAH.

Funding Acknowledgement

Type of funding sources: None. 3-years transplant-free survival

Right ventricular reverse remodeling assessed by echocardiography as a new goal-oriented treatment strategy in PAH patients

Background

While in heart failure with reduced ejection fraction, left ventricular reverse remodeling assessed by transthoracic echocardiography (TTE) is associated with better prognosis, right ventricular reverse remodeling (RVRR) was less investigated in pulmonary arterial hypertension (PAH)

Purpose

We aimed to investigate whether RVVR assessed by echocardiography could help to stratify PAH patient's prognosis.

Methods

Between 2002 and 2019, all consecutive PAH patients were included, treated and followed in a single PAH center in accordance with the current ESC/ERS guidelines. In addition to regular risk stratification parameters, we measured several echocardiographic RV systolic function and size parameters, including tricuspid annular plane systolic excursion (TAPSE, mm) or RV-end diastolic area (cm2) from apical-4 chamber view both at baseline, 1-year of follow-up as well as their change. Primary composite outcome was three-year transplant-free survival and death from all cause from the 1-year evaluation. Conditional inference trees were used to determine which TTE parameters and cutoffs values were associated with primary outcome from hierarchy of multiple covariates in multivariable Cox regression analysis. Kaplan-Meier curves were then drawn and compared with log-rank test.

Results

126 incident PAH patients were included (63% female, mean age 59±18 yo), mainly due to connectivite-tissue disease and idiopathic PAH (26% and 22% respectively). At baseline, mean pulmonary arterial pressure was 42 (33, 52) mmHg. At 1-y follow-up under pulmonary vasodilation therapy, NYHA (p&lt;0.01), NTproBNP (p&lt;0.01), mean pulmonary arterial pressure (p&lt;0.01) and cardiac index (p&lt;0.01) were significantly improved compared to baseline. Conditional inference trees showed that 1-year TAPSE gain &gt;1 mm and 1-year RV end-diastolic area decreased &gt;2 cm2 were associated with 3-year transplant-free survival in multivariable Cox regression analysis (HR=0.23, 95% CI [0.08–0.61] p=0,0035, HR=0.34, 95% CI [0.12–0.94], p=0.038). Simple score from 0 (absence of RVRR), 1 (partial RVRR) and 2 (complete RVRR), describing the number of TTE parameters reach at 1-year was then investigated. Patients with complete RVRR depicted better transplant-free survival than partial or absence of RVRR, log-rank p&lt;0.001 (figure).

Conclusion

Complete reverse remodeling from right ventricular size and function could represent a new goal-oriented treatment strategy in PAH patients.

Funding Acknowledgement

Type of funding sources: None. RVRR survival curves

Prognostic importance of Kidney, Heart and Interstitial lung diseases (KHI triad) in PH: A machine learning study

BACKGROUND

Pulmonary hypertension (PH) is a heterogeneous, severe and progressive disease with an impact on quality of life and life-expectancy despite specific therapies.

AIMS

(i) to compare prognosis significance of each PH subgroup in a cohort from a referral center, (ii) to identify phenotypically distinct high-risk PH patient using machine learning.

METHODS

Patients with PH were included from 2002 to 2019 and routinely followed-up. We collected clinical, laboratory, imaging and hemodynamic variables. Four-year survival rate of each subgroups was then compared. Next, phenotypic domains were imputed with 5 eigenvectors for missing values and filtered if the Pearson correlation coefficient was>0.6. Thereafter, agglomerative hierarchical clustering was used for grouping phenotypic variables and patients: a heat map was generated and participants were separated using Penalized Model-Based Clustering. P<0.05 was considered significant.

RESULTS

328 patients were prospectively included (mean age 63±18 yo, 46% male). PH secondary to left heart disease (PH-LHD) and lung disease (PH-LD) had a significantly increased mortality compared to pulmonary arterial hypertension (PAH) patients: HR=2.43, 95%CI=(1.24-4.73) and 2.95, 95%CI=(1.43-6.07) respectively. 25 phenotypic domains were pinpointed and 3 phenogroups identified. Phenogroup 3 had a significantly increased mortality (log-rank P=0.046) compared to the others and was remarkable for predominant pulmonary disease in older male, accumulating cardiovascular risk factors, and simultaneous three major comorbidities: coronary artery disease, chronic kidney disease and interstitial lung disease.

CONCLUSION

PH-LHD and PH-LD has 2-fold and 3-fold increase in mortality, respectively compared with PAH. PH patients with simultaneous kidney-cardiac-pulmonary comorbidities were identified as having high-risk of mortality. Specific targeted therapy in this phenogroup should be prospectively evaluated.

Case study: nefazodone for juvenile mood disorders

OBJECTIVE

Despite the increasing recognition of juvenile mood disorders, few medications have been shown to be effective. Nefazodone is a novel antidepressant that remains untested in children. Seven cases are described, including four with bipolar depression, in which nefazodone was used for depression.

METHOD

The authors systematically studied the response to nefazodone used naturalistically in seven treatment-refractory and very comorbid children and adolescents (mean age +/- SD, 12.4 + 3.1) with a juvenile mood disorder that was diagnosed clinically and confirmed by structured psychiatric interview. Response to treatment was evaluated retrospectively by an independent rater using the Clinical Global Impression (CGI) of severity and improvement of depression.

RESULTS

Children and adolescents received nefazodone for 13 (+/-8) weeks at a mean daily dose of 357 +/- 151 mg (3.4 mg/kg). Fifty-six percent of children and adolescents previously unresponsive to multiple medication trials manifested much to very much improvement as measured by the CGI. Two of four children with bipolar depression responded well to treatment, whereas the other two had mild manic activation. Overall, nefazodone was well tolerated, with adverse effects reported in only three subjects.

CONCLUSION

Nefazodone appears to be a well-tolerated compound that may provide a treatment option for juveniles with mood disorders. Further controlled trials are warranted.

Cardiovascular effects of therapeutic doses of tricyclic antidepressants in children and adolescents

OBJECTIVE

Tricyclic antidepressants (TCAs) play an important role in the treatment of pediatric psychiatric disorders. Despite widespread clinical use, concerns about their possible cardiovascular risk have arisen following several published reports of sudden death associated with their use in children. Accordingly, available evidence concerning TCA-associated cardiovascular effects in children and adolescents was surveyed.

METHOD

A systematic literature search from 1967 to 1996 identified relevant pediatric studies that evaluated cardiovascular effects of TCAs.

RESULTS

Twenty-four studies involving 730 children and adolescents given imipramine, amitriptyline, desipramine, or nortriptyline were found. TCA treatment was associated with minor increases in systolic and diastolic blood pressure, in heart rate, and in the electrocardiographic (ECG) conduction parameters, PR, QRS, and QTc. Holter ECG monitoring and exercise testing also revealed minor treatment effects. Some ECG changes related to specific TCAs emerged. Few age-related ECG differences in TCA-treated children, adolescents, or adults were detected. Associations of ECG abnormalities and relatively higher serum TCA levels were found.

CONCLUSION

TCA treatment in children and adolescents, like that in adults, is associated with cardiovascular changes of uncertain, but probably minor, clinical significance. More information is needed on the contribution of other physiological conditions on the cardiovascular system during exposure to TCAs. Guidelines for using TCAs in children and adolescents are presented.

Six-week, double-blind, placebo-controlled study of desipramine for adult attention deficit hyperactivity disorder

OBJECTIVE

Despite the increasing awareness of attention deficit hyperactivity disorder (ADHD) in adults, there are a limited number of controlled pharmacologic studies of this disorder; most of the trials have focused on the psychostimulants. Because the tricyclic anti-depressant desipramine has been found to be effective in treating ADHD in pediatric groups, the authors tested its efficacy in adults with ADHD.

METHOD

The authors conducted a randomized, 6-week, placebo-controlled, parallel-design study of desipramine at a target daily dose of 200 mg in 41 adult patients with DSM-III-R ADHD. They used standardized structured psychiatric instruments for diagnosis and, as the dependent variables (outcome), used separate assessments of ADHD, depressive, and anxiety symptoms at baseline and at each biweekly visit.

RESULTS

There were highly significant differences in the reduction of ADHD symptoms between adults receiving desipramine and placebo. Within the desipramine-treated group, there were clinically and statistically significant differences between baseline and the week 6 end point for 1) reduction of 12 of 14 symptoms of ADHD and 2) decreases in the broad categories of hyperactivity, impulsivity, and inattentiveness. In contrast, placebo-treated patients showed no differences between baseline and end point for any of the ADHD symptoms assessed. According to strict, predefined criteria for response, 68% of desipramine-treated subjects and no subjects in the placebo group were considered positive responders. Response to desipramine was independent of dose, level of impairment, gender, or lifetime psychiatric comorbidity with anxiety or depressive disorders.

CONCLUSIONS

These results, similar to findings in children and adolescents with ADHD, indicate that desipramine is effective in the treatment of ADHD in adults.

[Swallowed foreign bodies: problems, prognosis, and treatment (author's transl]

This is a report about 1465 cases of swallowed foreign bodies. Surgery is not necessarily indicated when foreign bodies are swallowed, because 90% of the objects are discharged spontaneously. Complications (perforation, ileus) occur only in 0.5% of the cases. Endoscopic extraction should be attempted; surgical removal is indicated only in cases of acute abdominal symptomatology or ileus. Foreign bodies can be left in the intestine for years without any noticable problems or pain (eight observed cases).